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

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

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

Note: if no EHR, PM or web software is primarily used, please also see assessment_provider_w/no_ehr

3. What is the percentage of your providers that currently maintain electronic records? 
(i.e. via EHR, PM, management agency, medical billing service, web tool)  % 

4. 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, Depression, Elderly

---------  PQRS participation

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

6. What was the primary PQRS submission method? 

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

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

(Please list the measure numbers)  

7. Would a small panel of prospective PQRS participants be interested in a pilot QCDR program for the 2014 PQRS 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 of the 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. 

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What is your email address? 

What is your phone number (please include extension)