Contact

Name

First

Last

Title [e.g., Dr, ARNP, PA-C, RN, Administrator]

Practice Name

Date Practice Opened

Number of sites

Estimated number of staff members

Estimated number of providers

Email

Phone Number

Practice website

Practice Address

Is your practice currently certified as a Patient Centered Medical Home? If yes, which organization did you go through (NCQA, AAAHC, TJC)?

What EMR do you have?

What EMR challenges do you have?

Are you aware of any state incentives for achieving PCMH?

What are your office hours?

Do you have evening or weekend hours?

Percentage of Medicaid patients:

Biggest commercial payer:

Are you doing patient satisfaction surveys?

Are you a "NO PAPER" office?

Are you a "hybrid" type of office. Some of your work is within the EMR and some is on paper charts, spreadsheets, or sticky notes?

What services do you offer in-house?

Do you have any of the following software products?

Do you employ/co-locate with any of the following?

When are you considering starting a PCMH project?

The Alliance for Pediatric Medical Homes