Practice Assessment

Your Name (required)

Your Email (required)

1) How many providers currently practice at your location:

2) Do you have an ancillary staff for Nursing, Scheduling, Billing, etc.?(required)
YesNo

3) If yes, please explain your ancillary staff setup (virtual staff, on-site staff):

4) Do you currently employ any physician extenders such as a PA or ARNP?
YesNo

5) At what facilities, do you currently have privileges?

6)What is the total number of patients served by your practice?

7)What is the approximate percentage of patient with the following medical conditions at your practice:

Diabetes: %
Hypertension: %
Asthma: %
COPD: %
CHF: %
Medicare Patients: %
Dual Eligible Patients (Medicare/Medicaid): %
Commercial Payers: %

8) Are you currently participating in any of the following programs:
MSSP (Medicare Shared Savigns Plan)PCMH (Patient Centered Medical Home)ACO (Accountable Care Organization)

9) Do you currently or have you ever attest to Meaningful Use?
YesNo

10) Do you participate in any specialized registry reporting such as GPRO, or through a professional organization such as the American Diabetic Association or American Heart Association?
YesNo

11) Do you currently or have you in the past reported to any quality programs such as PQRS or HEDIS?
YesNo

12) Will you be participating in MIPS for 2017?
YesNo

13) Which of the following patients does your practice accept?(Check all that apply):
MedicareMedicaidCommercial

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