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*indicates fileds that are required

Dear Dr,

We are in the process of updating our ACPNet membership database and would appreciate your help if you can please provide us with the following information.

*Name:
 
*E-mail:
 
Address:
 
Work phone:
 
Fax #:
 
Specialty (ies):
 
Name of practice site:

 

Type of practice setting: Urban Rural

Estimated percentage of your patients who meet the following criteria:

Gender: % Male % Female

Race:

% American Indian/Alaska Native

% Asian

% Black/African American

% White

% Native Hawaiian/Other Pacific Islander

% Other

Payor:

% Medicaid

% Medicare

% Private Insurance

% HMO

% Self Pay

% Other

Do you use Electronic Health Records in your practice: Yes No

Research experience and research interest (please type)

 


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

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