1. How many Medicare providers are members of your organization?   

2.What provider organization is most prevalent within your membership?   
Choose one Solo Practitioner Professional Association Medical Group Hospital Owned ACO HMO PPO Other - define in text box #10 below

------------ Report & Record keeping capabilities

3a. What percentage of your membership use a management agency (for scheduling/billing/etc)?

  %

3b. What percentage of your membership use a medical billing service
(this includes management agencies)?   %

3c. What percentage of your membership have a Smartphone?  %

3d. What percentage of your membership have a computer that has access to the internet?  %

3e. What percentage of your membership have a computer with an office suite
(with word processor, spreadsheet or database programs)?  %

4a. What is the primary method used by your providers for patient records?

Choose one Medical Billing Services Management agency (scheduling/billing) Web Based Tool Smart Phone App Word Processor Spreadsheet - Excel Database - Access Practice management SW EHR Pqper records Other - define in text box below

4b. What is the percentage of your providers that currently maintain electronic records? 
(i.e. via management agency, medical billing service, web, personal computer)  % 

5. Which patient record elements are commonly kept by your providers?  
Please type in the categories of information

Examples: Weight, Height, BP (Sys/Dias) A1c Lab results,
Hospitalization - Admin/Discharge, Rx/Prescriptions, Mobility, Mental acuity, Elderly

---------  PQRS participation

6a. What percentage of your membership has participated in PQRS in prior years?   %

6b. What was the primary PQRS submission method? 

Choose one Claims EHR Registry GPRO don't Know Other - notate in textbox below

6c. What measures were submitted by your providers?  Enter NA if not known.

(Please list the measure numbers)  

7. Would these prospective PQRS participants be interested in a pilot program for the 2014 reporting year?   Yes No

8. Please estimate the percentage of your membership will participate in PQRS during the 2015 reporting period?    %

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9. Please describe any specialty measures that your organization may wish to sponsor.

10. Please enter any other details here.

Feel free to elaborate on any answers provided above that you would deem helpful.

(example: list all methods used by your providers for patient records.

------------  Contact information

The following information enable us to contact you.  It will be confidential.

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What is your email address? 

What is your phone number (please include extension)