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Account information

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Job Title

Title: * ProviderOffice Manager/Practice AdministratorSales Executive/VendorConsultantManagement: non-clinicalOther

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Physician Information

NPI:

This is a 10 digit number. You can look up your NPI number here: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. The content of this field is kept private and will not be shown publicly.

Professional Information

First Name: *

Last Name: *

Provider Type: --MDDOPANPCNMWDDMDDSDMDDPMOther

Other Provider Type:

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Organization Name: *

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Organization Type: * Private Practice: Internal Medicine/Family PracticePrivate Practice: SpecialistGroup Practice: Internal Medicine/Family PracticeGroup Practice: SpecialistMulti-Specialty Group: Internal Medicine/Family PracticeMulti-Specialty Group: SpecialistHospitalCommunity Health CenterVendor: Health Information TechnologyHealth Plan/InsurerNon-ProfitGovernment AgencyOther HealthcareOther

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Other Organization Type:

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Telephone Number:

Format: 401-555-1212. With extension: 401-555-1212 x1234. The content of this field is kept private and will not be shown publicly.

How did you hear about us?: * --Referral from a Physician ColleagueSearch ResultAnother WebsiteRIQI Staff MemberFlyer or BrochureEmail NotificationOther

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Zip Code: *

Format: 12345 or 12345-1234. The content of this field is kept private and will not be shown publicly.

Using EHR?: * NoYes

Which EHR?: --AllscriptsAmazing ChartsAthena HealthCerner PowerCharteCLinicalWorkse-MDEpic SystemsGE CentricityGreenwayLighthouse MDMcKesson Provider Tech.MisysNextGenPolaris-EpicChartPractice PartnerSage-Intergy EHRSOAPwareOther

Other EHR:

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Disclosures:

Please specify any ownership or interest you hold in any related business or association. Please list the name of the business and the nature of the relationship.

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