The following information will enable us to contact you.

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Point of contact - Administrator
First Name:                                    
Last Name:                                    
Email address:                               
Phone (Include Extension)               

To expedite the setup of your account, please enter the following information:

Facility Name       
Address            
City          State 
Zip code   

Please answer the questions below as best you can. 

 1. What is the type of your organization?    Choose type of organization EP - Hospital CAH - Critical Access Hospital Urgent Care Clinic Nursing Home Registry/Consortium/Academy Hospital QCDR Other (Please describe in question #6)

 2. How many sites are affiliated with your organization?   Choose number of sites 1 2 3 to 5 5 to 10 Greater than 10

 3. Please describe your participating providers:
   3a. Total number of individual providers   Choose number of providers Solo - 1 2 to 24 25 to 99 100 and over  
            This includes all providers that bill CMS for services rendered using their NPI.
              Examples of types of providers: MD, DO, DDS/DMD, PA, NP, PT, OT, LCSW, Clinical Psychologist 

 4. Please select which software packages are used at your location.
 

     4a. Which Electronic Health Record (EHR) software is used at your practice?
           Select EHR software vendor Multiple vendors for each site - see question 6 ABELSoft Corporation Abraxas Medical Solutions Inc Advanced Data Systems Corporation Agastha, Inc. Allen Systems Group, Inc. AllMeds, Inc. Allscripts Professional Allscripts Enterprise AmazingCharts.com, Inc. American Medical Software AssistMed, Inc. athenahealth, Inc. Axolotl Corporation Benchmark Systems BizMatics, Inc. Business Computer Applications, Inc. CareData Solutions Corporation Catalis Cerner Corporation ChartConnect, Inc ChartLogic Clinix Medical Information Services, LLC Community Computer Service Companion Technologies CompuGroup Medical Conceptual MindWorks, Inc. Connexin Software, Inc. CPSI Criterions, LLC CureMD Corporation Department of Defense, Military Health System digiChart, Inc. Doctations, Inc. Document Storage Systems, Inc. eCast Corporation eClinicalWorks Eclipsys Corporation EHS Electronic Claims Processing Inc. d/b/a PBF Online e-MDs eMedicalFiles, Inc. Encite EncounterPRO Healthcare Resources, Inc. Epic Systems Family Health Centers of San Diego Inc. Gateway Electronic Medical Management Systems GE Healthcare Glenwood Systems, LLC gloStream, Inc. gMed, Inc. Greenway Medical Technologies Health Systems Technology, Inc Healthland, Inc. HealthPort Henry Schein Medical Systems HIT Services Group HPAS HS iMedica Corporation Indian Health Service Infor-Med Corporation Informatics Laboratories Corp Ingenix InteGreat Concepts, Inc. Integritas, Inc. Integrity On Site LLC, dba DocuTAP Intivia Intuitive Medical Software iSALUS Healthcare LSS Data Systems (Lake Superior Software) Marshfield Clinic McKesson Provider Technologies MDLAND MDTablet MedAppz, LLC MedAZ.net Medflow, Inc. Medical Communication Systems, LLC Medical Informatics Engineering Medical Messenger Medicat MedInformatix, Inc. MediNotes Corporation Meditab Software, Inc MedLink International, Inc MedPlexus, Inc. meridianEMR, Inc. Merritt Misys Healthcare Systems MTBC (Medical Transcription Billing Corporation) NCG Medical Systems, Inc. Netsmart Technologies NextGen Healthcare Information Systems Nightingale Informatix Corporation Noteworthy Medical Systems, Inc. Nuesoft Technologies, Inc. Ochsner Clinic Foundation OIS OmniMD Patient Account Management System Partners HealthCare System, Inc. Point and Click Solutions, Inc. Polaris Management, Inc. PowerMed Corporation Practice Partner PracticeOne Prime Clinical Systems, Inc. ProPractica Inc. Pulse Systems Purkinje Quality Systems Inc. RPMS/EHR Sage San Diego Hospitalist Physician Corp. Sequel Systems, Inc. Silk Information Systems, Inc. SOAPware, Inc. Spring Medical Systems SRSsoft SSIMED, LLC STI Computer Services, Inc. SynaMed, LLC SuccessEHS Total OutSource, Inc. TransMed Network UNI/CARE Systems, Inc. Universal EMR Solutions Universal Software Solutions Utech Products, Inc. Visionary Medical Systems Vitera Healthcare Solutions VODI Waiting Room Solutions Wellogic and GBA Health Network Systems Workflow.com, LLC WorldVistA
 

     4b. Which Practice Management system (PM) software is used at your location?
          Select Practice Management software vendor Multiple vendors for each site - see question 6 ABELSoft Corporation Abraxas Medical Solutions Inc Advanced Data Systems Corporation Agastha, Inc. Allen Systems Group, Inc. AllMeds, Inc. Allscripts AmazingCharts.com, Inc. American Medical Software AssistMed, Inc. athenahealth, Inc. Axolotl Corporation Benchmark Systems BizMatics, Inc. Business Computer Applications, Inc. CareData Solutions Corporation Catalis Cerner Corporation ChartConnect, Inc ChartLogic Clinix Medical Information Services, LLC Community Computer Service Companion Technologies CompuGroup Medical Conceptual MindWorks, Inc. Connexin Software, Inc. CPSI Criterions, LLC CureMD Corporation Department of Defense, Military Health System digiChart, Inc. Doctations, Inc. Document Storage Systems, Inc. eCast Corporation eClinicalWorks Eclipsys Corporation EHS Electronic Claims Processing Inc. d/b/a PBF Online e-MDs eMedicalFiles, Inc. Encite EncounterPRO Healthcare Resources, Inc. Epic Systems Family Health Centers of San Diego Inc. Gateway Electronic Medical Management Systems GE Healthcare Glenwood Systems, LLC gloStream, Inc. gMed, Inc. Greenway Medical Technologies Health Systems Technology, Inc Healthland, Inc. HealthPort Henry Schein Medical Systems HIT Services Group HPAS HS iMedica Corporation Indian Health Service Infor-Med Corporation Informatics Laboratories Corp Ingenix InteGreat Concepts, Inc. Integritas, Inc. Integrity On Site LLC, dba DocuTAP Intivia Intuitive Medical Software iSALUS Healthcare LSS Data Systems (Lake Superior Software) Marshfield Clinic McKesson Provider Technologies MDLAND MDTablet MedAppz, LLC MedAZ.net Medflow, Inc. Medical Communication Systems, LLC Medical Informatics Engineering Medical Messenger Medicat MedInformatix, Inc. MediNotes Corporation Meditab Software, Inc MedLink International, Inc MedPlexus, Inc. meridianEMR, Inc. Merritt Misys Healthcare Systems MTBC (Medical Transcription Billing Corporation) NCG Medical Systems, Inc. Netsmart Technologies NextGen Healthcare Information Systems Nightingale Informatix Corporation Noteworthy Medical Systems, Inc. Nuesoft Technologies, Inc. Ochsner Clinic Foundation OIS OmniMD Partners HealthCare System, Inc. Patient Account Management System Point and Click Solutions, Inc. Polaris Management, Inc. PowerMed Corporation Practice Partner PracticeOne Prime Clinical Systems, Inc. ProPractica Inc. Pulse Systems Purkinje Quality Systems Inc. RPMS/EHR Sage San Diego Hospitalist Physician Corp. Sequel Systems, Inc. Silk Information Systems, Inc. SOAPware, Inc. Spring Medical Systems SRSsoft SSIMED, LLC STI Computer Services, Inc. SuccessEHS SynaMed, LLC Total OutSource, Inc. TransMed Network UNI/CARE Systems, Inc. Universal EMR Solutions Universal Software Solutions Utech Products, Inc. Visionary Medical Systems Vitera Healthcare Solutions VODI Waiting Room Solutions Wellogic and GBA Health Network Systems Workflow.com, LLC WorldVistA
          If   1) Your software vendor is not listed, or
                  2) You use an alternative patient record keeping system, OR
                  3) Multiple vendors are used at your locations,
                          please list the details in question #6.

5. Has your your organization participated in eCQM reporting in prior years?  Choose one Yes No Don't know             

    If you have reported eCQM or IQR in a prior period, please answer the following questions:
    5a. What year(s) did your organization report? 
    5b. Tell us about your previous experience:
            What eCQM or IQR measures have you previously reported?
            What patient data format(s) have you exported (QRDA1, CCDA, CCD, CSV, XLS...)
           
          

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6. Please enter below any additional information that you would deem helpful.