Health ePractice Callback Request Form
     
Practice Name:
Street Address:
 City:
State:
 Zip Code:
Office Number:
 Specialty:
  
# of Locations:
 # of Physicians:
 # of Mid Level Providers:
# of Residents:
 Tax ID # used by practice:
  
Physician(s):
Main Point of Contact:
 Title:
 Email:
Contact Number:
 # of Computers?
  
Product Demos of Interest: Tools Scheduled Date
eClinicalWorks EMR Pick a date
Cerner EMR Pick a date
Wellcentive Pick a date
Patient Portal Pick a date
HIE Pick a date
eRX / Disease Registry Pick a date
Practice Management Scheduling/Billing System:
Do you schedule on paper?
Yes No 		Do you fax your billing sheets to an offsite biller?
Yes No
Are you utilizing an EMR today? Yes No If yes, what?
Are you using an eRx or disease registry? Yes No If yes, what?
What do you hope to accomplish by implementing an EMR?
What are your short term expectations?
Barriers and Concerns?