Intake Assessment
Thank you for your interest in the PCMH project sponsored by FCAAP and Sunshine Health. Please complete this assessment to help us learn about your practice. This assessment is not a guaranteed spot into the PCMH project.
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
Best Contact 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?
*
Do you have any of the following software products?
*
CHADIS
Phreesia
Telehealth platform
Patient portal
Patient recallers/reminders
Percentage of Medicaid/ managed Medicaid patients:
*
Are you currently receiving MPIP incentives with Florida Managed Medicaid Plans? If so, please list the plans giving incentives.
*
This project is co- sponsored by Sunshine Health. Do you accept Sunshine Health?
*
Yes
No
Largest commercial payer:
*
This project is co-sponsored by FCAAP. Are you a current Florida Chapter of the American Academy of Pediatrics member [FCAAP] ?
*
Yes
No
If you are not a member of FCAAP, would you be willing to become a member. The cost is $200 a year.
*
Yes
No
Are you currently certified as a Patient-Centered Medical Home with any of the following organizations?
*
NCQA
AAAHC
TJC
URAC
None
What are your office hours?
*
Do you have evening or weekend hours?
*
If you do not have extended hours, would you be willing to extend at least one hour a week outside of regular business hours?
*
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
How is your billing handled?
*
In-house
External billing company
Partnered with EMR/ Practice Management System
What types of chronic conditions do you see in your patient population?
*
Asthma
Obesity
Premature Infants
ADHD
Depression/Anxiety
Social/mood disorders
Diabetes
Developmental Delays
Autism
Cerebral Palsy
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 employ/co-locate with any of the following?
*
Nutrtionist
Lactation Specialist
LCSW/Counselor
Psychiatry
None
Do you agree to fully participate in the PCMH program? Implementing any necessary workflows.
*
Yes
No
Submit
Should be Empty: