* Indicates a required field.

• *Contact Person
• *Practice/Center Name
• *Provider First Name
• *Provider Last Name
• *Type of Practice/Specialty
• *Address
• *City
• State
  Pennsylvania
• *Zip Code
• *Phone
  format
• Fax
  format
• *E-mail Address
• *Number of primary care physicians in practice
• *Number of other primary care providers
  (nurse practitioners, etc.)
• This practice is currently using an EHR system:
  Yes
  No
• This practice is owned by another entity:

  Yes
  No
• Preferred technical assistance support:
  No preference
  Pennsylvania Academy of Family Physicians
  PMSCO Healthcare Consulting
  Public Health Management Corporation
  Quality Insights of Pennsylvania
• Click to submit