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Application for NCAHEC'S Primary Care Consulting Services

* Required Fields

Entity/Organization Information
* Tax ID Number:
-   

* What's the legal business name associated with this Tax ID Number?

  

* How many geographic locations(sites) that perform primary care are covered by this Tax ID?

* How many patient encounters per year? (Estimate)

* How many unique patients per year? (Estimate)

* Patient insurance mix (Estimate)

% Medicare
% Medicaid
% Sliding Fee
% Private Insurance
% Self pay
Total

* Number of Support Staff at the Practice?

* Business address associated with this Tax ID?

* City

* State

* ZIP

* Phone

- -

Fax

- -

Email
Practice Information

* Practice Name

* Practice Address

 

* City

* County

* State

* ZIP

* Phone

- -

FAX

- -

Email

Practice Contact

* First Name

* Last Name

Title

Address


City

State

ZIP

* Phone

- -

FAX

- -

* Email

Practice Details

How many prescribing providers are in your practice?

* What is your practice type?

Organization
 

Does your practice see Medicare patients?

  

Does your practice see Medicaid patients?

  

What is your specialty?

If other, please specify

Are you owned by a hospital or health system?

  

If yes, name of hospital or health system

Add a Provider (* Required fields)
If other, please specify

 

EHR Project Plans

* At the time of this application,
where is your practice in the EHR
implementation process?


If other, please explain
If you have an EHR, please select the name and version.