2014 Member Census Form

Member Information

Practice Name
Member First Name
Last Name
Specialty
Primary Address
City State Zip
Phone Fax
Email

Practice Information

Number of:Physicians in your Practice
Mid-Level Providers
Are you:Employed by a hospital network
 A member of an independent practice
Name of EHR in use
Practice Management System (if different)
 
Meaningful Use Program Medicare Medicaid
Stage/Year Achieved in 2013
Do you plan to continue participation in the Meaningful Use Incentive Program?
 

Member Benefits Information

Please check below if you would like us to contact you about:
 FREE IT Services Check-upICD-10
 Meaningful Use SupportLegal Questions
 Practice Operations IssuesIT Issues
 Insurance QuestionsCollections Issues
 PCMH
Other Information
Practice/Office Manager
Practice/Office Manager Email
Practice/Office Manager Phone
 
   - denotes required fields

2014 OOA
Member Census

  • FREE IT Services Checkup
  • Chance to win $100 Visa Gift Card
  • Access to other Members-only Benefits

Update Information Now

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