EDCC Discovery Form

The Emergency Department Care Coordination (EDCC) Program in Virginia was created to provide a single, statewide technology solution that facilitates real-time communication and collaboration among physicians, outpatient health care providers, and clinical and care management personnel for patients receiving services in hospitals and across the care continuum, for the purpose of improving the quality of patient care services.

To begin, please help us better understand your organization by taking a few minutes to complete the form below. After submission, a Virginia Health Information representative will review your information and contact you regarding next steps. The discovery process helps us to determine existing organizational structure, partnerships, and workflows and how to best serve your organization.
Your Information
Name*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Organization Information
Organization Name:*
Organization NPI:
DBA/Preferred Name:*
NPI Taxonomy Description:
Drug Enforcement Agency (DEA) Number(s):
State Corporation Commission (SCC) ID(s):
Address 1:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone Number
Please enter a valid phone number.
Email
example@example.com
Website
Does your organization have multiple locations?*

YesNo
If yes, how many?
Please provide names and locations:
If you are a large organization, please provide a list of locations in a separate document or spreadsheet.
Is your organization affiliated with any other organizations?*

YesNo
If yes, provide details:
Please list any partnerships your organization participates in—we might find places where communication and collaboration can occur.

Contact Information
Will you be serving as the primary point of contact for onboarding?

YesNo
Primary Contact:*

First NameLast Name
Title:*
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Designated Signatory for the EXCHANGE Trust Agreement (if different from name above):

First NameLast Name
Title:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Clinical Contact:*

First NameLast Name
Title:*
Email:*
example@example.com
Phone Number:
Please enter a valid phone number.
IT Contact:*

First NameLast Name
Title:*
Email:*
example@example.com
Phone Number:
Please enter a valid phone number.
Accounts Payable (A/P) Contact:

First NameLast Name
Title:
Email
example@example.com
Phone Number
Please enter a valid phone number.

Personnel & Patient Services Information
Estimated volume of patients:*
Estimated number of personnel at your organization:*
Are all personnel directly employed by your organization?*

YesNo
If no, please explain:
What types of providers do you have on staff? (e.g., MD, DO, PA, NP, RN, LCSW, MA, etc.)*
Does your organization have staff who participate in case management?*
Does your organization have dedicated staff for utilization review?*
Please provide a brief description of patient services provided by your organization:*
Please classify your organization according to your own definitions (e.g., PCP, FQHC, SNF, behavioral health, SUD, etc.):*
Are any of your providers or patient services protected under 42 CFR Part2 (e.g., substance use treatment, etc.):*

YesNoUnsure
Is your clinic providing MAT Services?*

YesNo
If yes, what sort of workflows currently exist for providing ongoing MAT interventions to patients with Opioid Use Disorder (OUD)?
If yes, are your MAT clinic providers currently administering buprenorphine? Are they prescribing suboxone for thesepatients with OUD?
If yes, What are your current workflows for receiving patients from the hospital to your MAT clinic?

Technical Information
Does your organization currently use an EMR / EHR?*

YesNo
If yes, which one?
Does your organization have IT resources available?

YesNo
If yes, are they provided by an outside party?

YesNo
The EDCC Program requires a ‘Patient File’ to be provided on a regular interval (.e.g, daily, weekly, or monthly). This file would include basic patient demographic and provider information. Would your organization be able to meet this requirement?*

YesNo

Additional Information
Is there any other information you feel would be beneficial to provide at this time?
Should be Empty: