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Chronic
Care
About Us
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Chronic Care Management
Principal Care Management
Transitional Care Management
Remote Patient Monitoring
Remote Therapeutic Monitoring
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Physician Groups
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Long-Term Care
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Contact Us
Pharmacy Intake Form:
Legal Pharmacy Name:
Tax ID (EIN):
NCPDP Number:
Main Pharmacy Address:
Fax Number:
Primary Contact Name:
Email:
DBA (If applicable):
NPI (Type 2 - Organization)
DEA Number (if applicable):
Phone Number:
Website:
Title/Position:
Direct Phone:
Type of Pharmacy Ownership:
Independent Pharmacy
Chain Pharmacy
Health System-Owned
Specialty Pharmacy
LTC Pharmacy
Compounding Pharmacy
Clinical Services Currently Offered:
Medication Therapy Management (MTM)
Comprehensive Medication Review (CMR)
Adherence Packaging
Immunizations
Smoking Cessation
Other
Number of Locations:
Number of Pharmacy Technicians:
Can Your System Export Reports:
YES
NO
State Board of Pharmacy License Active:
YES
NO
Number of Pharmacists:
Pharmacy Management System (PMS):
Professional Liability Insurance Active:
YES
NO
Any Recent Audits or Sanctions:
YES
NO
Your Primary Goals in Partnering with ChronicCare:
Increase Clinical Revenue
Improve Medication Adherence
Differentiate from Competitors
Support CCM/RPM Programs
Other
Would You Consider Launching a Collaboration Within 30-60Days:
YES
NEED MORE INFORMATION
NOT AT THIS TIME
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