The following information will enable us to contact you.

--------------------------------------
Point of contact - Office Administrator

First Name:                                    
Last Name:                                    
Email address:                               
Phone (Include Extension)               

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

NPI             (If organization, specify QI administrator NPI here)
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 ACO BHO Hospital Owned Medical Group Professional Association Solo practitioner Registry/Consortium/Academy QCDR Other (Please describe in question #6)

 2. How many practice 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 

   3b. Select the primary specialty of your practice:    Select a Specialty General Medicine Pediatrics Internal Medicine Family Medicine Adult Nurse Practitioner Advanced Nurse Practitioner Allergy/Immunology Ambulance Ambulatory Surgery Center Anesthesiology Audiology Behavioral Health Cardiology Cardiovascular Disease Chiropractic Child & Adolescent Psychiatry Clinical Nurse Specialist Counselor Critical Care Medicine Dental Dentistry Dermatology Diabetic Supplies/Mail Order Diagnostic & Therapeutic Radiology Diagnostic Radiology Dietitian Durable Medical Equipment & Medical Supplies Electrophysiology Emergency Medicine Endocrinology Family Medicine Family Nurse Practitioner Family Planning Gastroenterology General Practice General Surgery Geriatrics GYN Oncology Gynecology Hearing Aids Hematology Hematology/Oncology Home Health Home Infusion Pharmacies Hospice Hospitalist In Home Hyperalimentation Supplies Infectious Diseases Infusion Services Internal Medicine Interventional Cardiology Lab Services Long Term Care Mail Order Maternal-Fetal Medicine Medical Oncology Mental Health - Outpatient Midwife Neonatology Nephrology Neurology Neuropsychology Neurosurgery Nurse Practitioner Obstetrics/Gynecology Occupational Therapy Ophthalmology Optometry Oral & Maxillofacial Surgery Orthopedic Products Orthopedic Surgery Orthopedics Otolaryngology Pain Medicine Palliative Care Pathology Pediatric Allergy & Immunology Pediatric Audiology Pediatric Cardiology Pediatric Critical Care Pediatric Dermatology Pediatric Dietitian Pediatric Endocrinology Pediatric Gastroenterology Pediatric Genetics Pediatric Hematology/Oncology Pediatric Home Health Pediatric Hospice/Palliative Pediatric Hospitalist Pediatric Infectious Disease Pediatric Internal Medicine Pediatric Nephrology Pediatric Neurology Pediatric Neuropsychology Pediatric Neurosurgery Pediatric Nurse Practitioner Pediatric Occupational Therapy Pediatric Oncology Pediatric Ophthalmology Pediatric Oral Surgery Pediatric Orthopedic Surgery Pediatric Otolaryngology Pediatric Physical Therapy Pediatric Plastic Surgery Pediatric Psychiatry Pediatric Psychology Pediatric Pulmonology Pediatric Rehabilitation Pediatric Rheumatology Pediatric Social Worker Pediatric Speech Pathology Pediatric Surgery Pediatric Urology Pediatrics/Adolescent Perinatology Pharmacy Clinical Pharmacy PIC Physical Medicine & Rehabilitation Physical Therapy Physician Assistant Plastic & Reconstructive Surgery Plastic Surgery Podiatry Prosthetic Limbs Psychiatric Hospital Psychiatry Psychology PT OT ST SLP Pulmonology Radiation Oncology Radiology Rehabilitation - Inpatient BH Rehabilitation - Outpatient Rehabilitation In-Patient Rehabilitation Outpatient Rehabilitation Outpatient /SUD Rehabilitation Outpatient SUD Renal Dialysis - Outptient Retail Pharmacies Rheumatology Skilled Nursing Facility Sleep Center Social Worker - LMSW Social Worker - MSW Social Worker-LCSW Speech Pathology Sport Medicine Sports Medicine & Therapy Substance Abuse Rehab Facility Surgical Services Therapist Therapy - Outpatient Occupational/Physical Therapy - Outpatient Speech Transportation Urgent Care Urology Vocational Nurse Vascular Medicine
        If your specialty is not listed, or multiple specialties practice at your location(s),
            please list specialty information in question #6.

 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 We do not use EHR software 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 We do not use Practice Management software 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 QPP reporting in prior years?  Choose one Yes No Don't know             

    If you have reported QPP in a prior period, please answer the following questions:
    5a. What year(s) did your organization report? 
    5b. What primary QPP reporting method was used?  Choose prior QPP report method(s) Claims DSV - Open DSV - Closed EHR GPRO Registry
    5c. Tell us about your previous experience:
            What report data format(s) have you generated (CSV, QRDA1, CCD, CCDA, don't know)
            If applicable, What measures and/or measure groups have you previously reported?
          

============================================

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