ACPNet Logo

*indicates fileds that are required

Your contact information:

*Name:
 
*ACP #:
 
*E-mail:
 
Address:

 

Your personal information:

2. Gender: Male female

3a. Which of the following racial category best describes you?

American Indian/Alaska Native

Asian

Black/African American

White

Native Hawaiian/Other Pacific Islander

Other

3b. Your ethnicity: Hispanic Not Hispanic

Your professional information

4. Specialty/Subspecialty:

5. Are you affiliated with an Institutional Review Board (IRB)?
Yes No

6. Are you covered by a Federal Wide Assurance?
Yes No

7. Have you ever participated in an established PBRN?
Yes No

8. At how many different office locations do you see ambulatory patients?
Number of office locations:

9. Who owns your main practice (where you see the most patients)?

Physician/physician group

Hospital

Other health care corporation

HMO

Other (explain):

10. How large is your main practice (where you see the most patients)?

Number of physicians:
 
Number of clinical support staff:
 
Number of lay support staff:
 
Number of patient visits per week:

 

11. How many patients do you see in an average week?
On average patients per week

12. Does the practice you work in have a computer?
Yes No

If yes, what do you use it for?

Scheduling

Patient billing

Insurance claims

Electronic medical records

Other (explain):

13. Please list your research experience and research interests:

Please estimate the percentage of your patients who meet the following criteria: (please write numbers in the boxes)

Gender: % Male % Female

Race:

% American Indian/Alaska Native

% Asian

% Black/African American

% White

% Native Hawaiian/Other Pacific Islander

Payor:

% Medicaid

% Medicare

% Private Insurance

% HMO

% Self Pay

% Other

 


Thank you for completing the Physician Information Form.
Questions? Please call Meghan Gannon at 1-800-523-1546 x2847 or email acpnet@acponline.org

Page updated: 5-12-06

Discussion Groups

Multimedia Learning Resources
Related Links

New ACP Online Clinical Information Page

New ACP Online Clinical Information Page
Sneak a peek at ACP's new and improved Clinical Information page! Test drive the beta version of our redesigned Clinical Information landing page, give us your feedback, and help us make it as easy to use as possible.

Your Opinion Counts

Your Opinion Counts

Twice a year, ACP participates in a journal readership survey of random internists. If you receive one of these surveys in the mail, please indicate if you read our journals and answer the questions about your reading habits of our journals.

Your voice in these surveys is very important to ACP and enables us to continue to produce the high-quality publications that you expect.
Find out more.