DOQ-IT Information Request Form

Note: The enrollment deadline for the DOQ-IT project is August 1st, 2006. Any practices/persons requesting gmcf's DOQ-IT services after then should complete the Information Request Form below in order to participate in the next enrollment period, which is November 2007. A gmcf representative will contact you once the request is submitted.

Fields labeled * are required.

Practice Information
* Practice Name:
* Practice Address:
* City:
* State:
* ZIP Code:
* County:
* Practice Phone Number:
Practice Web Site:
Primary Contact Information
* Primary Contact First Name:
* Primary Contact Last Name:
* Title:
* Primary Contact Phone Number:
* Primary Contact E-Mail:
* Specialty:
* Number of Physicians or Billable Providers:
* Number of Locations:
Patient Population
* Number of Active Patients:
* Number of Medicare Patients:
* What Percentage of Your Medicare Patients Are African-American?
* What Percentage of Your Medicare Patients Are Hispanic?
* Are You in the Process of Selecting an EHR Vendor?
What Is Your Potential Budget for Purchasing an EHR System?
* Do You Currently Have an EHR System?
If Yes, Vendor Name:
If No, How Soon Do You Expect to Implement an EHR System?
* How Did You Hear About DOQ-IT?