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Practice or Hospital Name:*
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Please indicate your specialty
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If you selected "other" please indicate specialty:
How many providers are in your practice:*
How does your practice maintain patient records
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Electronic Health/Medical Record:
Which contracted services are you interested in
EHR Selection:
EHR Implementation:
EHR Workflow:
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Understanding Medicare/Medicaid Incentive Programs:
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If you selected "other" service please indicate:
What is the status of your PM or Billing system
Plan to Implement:
Not Interested:
If already implemented who is the vendor:
What is the status of EHR/EMR in your practice
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Not Interested in Implementing EMR/EHR:
If already implemented indicate vendor:
What is the status of ePrescribing in the practice
Plan to Implement ePrescribing:
Not Interested in Implementing ePrescribing:
If already implemented indicate vendor:
Please describe any other technology implemented:
If you do not have EHR/EMR when will you implement
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4-7 months:
8-12 months:
13 + months:
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