IPANY Practice Assessment
Physician Level Detail
Provider FN + LN
*
First Name
Last Name
Provider DOB
*
-
Month
-
Day
Year
Date of Birth
Provider Designation
Please Select
ABA
CNM
CNP
CRNA
DNP
DO
DPM
DPT
FNP
FNP RN
LCSW
LMHC
MD
Midwife
NP
PA
PA-C
PhD
PMHNP
PT
RD
SLP
Provider Primary Specialty
*
Please Select
Addiction Medicine
Allergy Immunology
Anesthesiology
Audiologist
Cardiac Surgery
Cardiology
Certified Clinical Nurse Specialist
Certified Nurse Midwife
Certified Registered Nurse Anesthetist(CRNA)
Chiropractic
Clinical Psychologist
Colorectal Surgery
Critical Care (Intensivists)
Dermatology
Diagnostic Radiology
Emergency Medicine
Endocrinology
Family Practice
Gastroenterology
General Practice
General Surgery
Geriatric Medicine
Gynecological/Oncology
Hand Surgery
Hematology
Hematology/Oncology
Independent Diagnostic
Infectious Disease
Internal Medicine
Interventional Pain Management
Interventional Radiology
Licensed Clinical Social Worker
Licensed Mental Health Counselor
Mammography Screening
Maxillofacial Surgery
Medical Oncology
Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear Medicine
Nurse Practitioner
Obstetrics Gynecology
Occupational Therapist
Ophthalmology
Optician
Optometry
Oral Surgery (dental only)
Orthopedic Surgery
Orthotist
Osteopathic Manipulative
Otolaryngology
Pain Management
Pathology
Pediatric Medicine
Peripheral Vascular Disease
Physical Therapist
Physician Assistant
Plastic and Reconstructive
Podiatry
Preventive Medicine
Prosthetist
Prosthetist-Orthotist
Psychiatry
Psychologist
Public Health or Welfare
Pulmonary Disease
Radiology
Radiation Oncology
Radiation Therapy Center
Registered Dietitian/Nutrition
Rehabilitation
Rheumatology
Surgery
Surgical Oncology
Thoracic Surgery
Urology
Vascular Surgery
Provider Individual Email
*
example@example.com
Provider NPI
*
Provider CAQH Number
*
Medicare Number
*
Medicaid Number
Provider SSN
*
No Dashes
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Practice Location list (Include all where the provider is practicing)
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Group Level Information
Group Name
*
Doing Business As (dba)
Optional
Group Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code +4
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is Mailing address and Billing address the same?
*
Yes
No
Billing Address (ONLY FILL OUT IF THIS ADDRESS IS DIFFERENT FROM MAILING ADDRESS)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Types
*
Line of Business
*
Group Taxonomy
*
To find your Group's Taxonomy #, visit https://npiregistry.cms.hhs.gov/
Group Specialty Information
*
Single Specialty
Multi Specialty
Other
Group Financial Information
Group Financial Information
Tax Classification
*
Group Tax ID Number (TIN)
*
Electronic Health Record (EHR) Platform
*
Please Select
Epic Systems
Cerner
Allscripts
Athenahealth
Meditech
NextGen Healthcare
eClinicalWorks
Practice Fusion
Greenway Health
Kareo
Sunrise EHR (by Allscripts)
GE Healthcare Centricity
McKesson (HealthQuest)
IntelliCare
AdvancedMD
Surescripts
ChartLogic
Harris CareTracker
ZirMed
Elation Health
EpicCare
Medical Informatics Corp.
PointClickCare
Vitalware
Other
If other EHR and not listed, please enter here
W9 Form
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Group Contact Information
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Optional
Format: (000) 000-0000.
Group Practice Assessment
Primary Practice Location Details ( Please fill out for each practice location)
Practice Name
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code + 4
Office Hours
*
Is Primary Practice?
*
Yes
No
Federal Tax ID
*
Practice NPI
*
Practice Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Email
*
example@example.com
Does your group provide services in any other language other than English?
*
Yes
No
If yes, what language?
Are you accepting new patients?
*
Yes
No
Is this Practice Location ADA compliant?
*
Yes
No
Are you Accredited?
*
Yes
No
Patient Age Range
*
i.e 0-99
Practice Effective Date
*
-
Month
-
Day
Year
After Hours Service
*
Please Select
Voicemail
Answering Service
N/A
Office Manager Name
*
First Name
Last Name
Office Manager Email
example@example.com
Submit
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