PBACO - Enroll

PRACTICE INFORMATION:

TIN Name

TIN Number

Practice Address/es

Billing Address (if different)

Practice Phone Number

Fax Number

TIN Owner/s Name

TIN Owner/s Email

TIN Owner Cell

Preferred Contact Method

Please list all Physicians / PA’s / ARNP’s:

Are you currently in an ACO or Value Based Care Program? If so, which one?

Membership Type:

PCP

Specialist

Multispecialty

Preferred Days/Times to Meet with the ACO

Office Manager Name

Office Manager Phone

Office Manager Email

Do you have an EMR? If so, which one and which version

Hours of Operation

How often do you see your chronically ill patients?

Are you interested in using the ACO Call Center or having a consultant call out of your practice to assist you with scheduling?

What would you classify your practice as? (Family Practice, Pulmonology, Nephrology, Geriatrics, etc.)

Do you have a secondary specialty?

Do you work in any other healthcare setting? (SNF, Hospice, ER, Hospital, ALF) If so, which one/s?

Are you a medical director at any facility or home health agency? If so, which ones?

Name of signee:

Oops! Something went wrong while submitting the form.