OHIP is funded through the Office of the National Coordinator, Dept. of Health and Human Services, grant numbers 90RC0012 and 90HT0024

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1 Insert Regional Partner Logo Here Organization Name (as identified on contract): Practice Intake Form All the information on this form is required. It will be used for entry into a management tool. The information provided should be the practice's best estimate at the time the form is completed. addresses will be used to provide you with educational updates on REC and HIE services. You will have the ability to unsubscribe from these updates at any time. Organization Information for Practice OHIP is funded through the Office of the National Coordinator, Dept. of Health and Human Services, grant numbers 90RC0012 and 90HT0024 Please print legibly Organization Type: Private Practice 1-10 Rural Health Clinic Community Health Center/FQHC Critical Access Hospital Other Underserved Setting Rural Hospital Private Practice 11+ Non Priority Hospital Public Hospital Other Priority Setting Practice Consortium Specialty Practice Organization Size: Solo 2-3 Providers 6-10 Providers 11+ Providers 4-5 Providers Organizational NPI: Organizational Tax ID #: Organization Address: Is this address the main site? Yes No Main Contact Name: (first & last) Phone: OHIP is funded through the Office of the National Coordinator, U.S. Dept. of Health & Human Services, grant numbers 90RC0012 and 90HT0024 REC CRM Required Information Version 3.0 4/14/11 Pg. 1

2 OHIP is funded through the Office of the National Coordinator, U.S. Dept. of Health & Human Services, grant numbers 90RC0012 and 90HT0024 REC CRM Required Information Version 3.0 4/14/11 Pg. 2

3 EHR Information to be completed by the Practice Existing EHR Yes No Existing EHR Go Live Date / / Primary Care EHR (Specify Vendor) Other Primary Care EHR (Specify Vendor) Primary Care EHR Version Primary EHR Type Software as a Service (SaaS)* Installed Software* Integrated with Practice Yes No Management System Practice Management System (Specify Vendor) Specialty EHR (Specify Vendor) Other Specialty EHR (Specify Vendor) Specialty EHR Version Specialty EHR Type Software as a Service (SaaS)* Installed Software* Specialty Integrated with PMS Yes No *SaaS (Software as a Service) or ASP (Application Service Provider) is the EHR vendor that houses and supports the hardware servers and software and the physician/provider pays for a license to connect to EHR applications over the internet. *Installed Software is when the physician/provider buys, houses and supports hardware servers for their office with the EHR software installed. REC CRM Required Information Version 3.0 4/14/11 Pg. 3

4 Federally Qualified Health Center? Yes No # of Participating Providers at Practice # of Practice Sites If more than one site, please fill out page 4 # of Support Staff # of Patient Encounters Per Year (the total number of patient visits in a year-counts reoccurences) # of Unique Patients Per Year (the total number of patients in a year- does not count reoccurences) % of Patients on Medicaid % of Patients on Medicare Practice Demographics to be completed by the Practice Information provided may be estimated % of Patients on Private Insurance % of Patients Uninsured Contact Information to be completed for each Provider in Practice Please include a separate sheet if necessary. All criteria below is required for EACH provider. Physician Name (as identified on contract) Provider 1 Provider 2 Provider 3 Provider 4 Credentials Phone Specialty Individual NPI ID Medical License # Site Name REC CRM Required Information Version 3.0 4/14/11 Pg. 4

5 Site Information REC CRM Required Information Version 3.0 4/14/11 Pg. 5

6 # of Providers at site REC CRM Required Information Version 3.0 4/14/11 Pg. 6

7 REC CRM Required Information Version 3.0 4/14/11 Pg. 7