Intake Assessment
Thank you for your interest in PCS. Please complete this assessment to help us learn about your practice.
Name
First Name
Last Name
Title [e.g., Dr, ARNP, PA-C, RN, Administrator]
Practice Name
Date Opened
Number of sites
Estimated number of staff members
Estimated number of providers
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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?
Yes
No
Are you a "NO PAPER" office?
Yes
No
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?
Yes
No
What services do you offer in-house?
Behavioral health management
Fluoride varnish application
COVID testing
COVID vaccine
Asthma care [breathing treatments, spirometry, medication management]
Hearing/Vision assessments
Do you have any of the following software products?
CHADIS
Phreesia
Telehealth platform
Patient portal
Patient recallers/reminders
Do you employ/co-locate with any of the following?
Nutrtionist
Lactation Specialist
LCSW/Counselor
Psychiatry
When are you considering starting a PCMH project?
ASAP
3-6 months
6-12 months
12+ months
Submit
Should be Empty: