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PRACTICE INFORMATION

TIN Name:

TIN Number:

Practice Address/es:

Billing Address (if different):

Practice Phone Number:

Fax Number

TIN Owner/s Name

TIN Owner/s Email

TIN Owner Cell

Preferred Contact Method

Please list all Physicians / PA’s / ARNP’s:

Are you currently in an ACO or Value Based Care Program? If so, which one?

Membership Type:

PCP

Specialist

Multispecialty

Preferred Days/Times to Meet with the ACO:

Office Manager Name:

Office Manager Phone:

Office Manager Email:

Do you have an EMR? If so, which one and which version:

Hours of Operation:

How often do you see your chronically ill patients?

Are you interested in using the ACO Call Center or having a consultant call out of your practice to assist you with scheduling?

What would you classify your practice as? (Family Practice, Pulmonology, Nephrology, Geriatrics, etc.)

Do you have a secondary specialty?

Do you work in any other healthcare setting? (SNF, Hospice, ER, Hospital, ALF) If so, which one/s?

Are you a medical director at any facility or home health agency? If so, which ones?

Name of signee:

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