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Chronic
Care
About Us
Solutions
Chronic Care Management
Principal Care Management
Transitional Care Management
Remote Patient Monitoring
Remote Therapeutic Monitoring
Who We Serve
Physician Groups
Health Insurance/Payors
Long-Term Care
Resources
Blog
Careers
Webinar
Contact Us
Physician Practice Intake Form:
Legal Practice Name:
Tax ID (EIN):
Main Practice Address:
Email:
Total Number of Providers:
Company Website:
DBA (If applicable):
Group NPI (Type 2):
Number of Participating Clinic Locations:
Phone:
Primary Contact:
Title/Position:
Practice Type:
Independent
Hospital-Owned
FQHC
RHC
ACO
Other
Medicare PTANs Available?
YES
NO
Medicaid Enrollment Active?
YES
NO
Total Active Patient Panel:
Percent of Panel on Medicare Advantage:
Percent of Panel on Commercial Insurance:
Common Conditions Treated:
Diabetes
Hypertension
Heart Failure
COPD/Asthma
Chronic Kidney Disease
Depression
Other
Percent of Panel on Medicare:
Percent of Panel on Medicaid:
Percent of Panel on Commercial Insurance:
Common Languages Spoken by Patients:
English
Spanish
French/Creole
Mandarin
Arabic
Other
Your EMR/EHR System:
Clearinghouse:
Billing Company (if applicable):
Primary Billing Contact:
Which Services Are You Interested In Starting?:
Chronic Care Management (CCM)
Remote Patient Monitoring (RPM)
Transitional Care Management (TCM)
Principal Care Management (PCM)
Remote Therapeutic Monitoring (RTM)
Other
Select Your Time Zone:
UTC - 04:00 US Eastern
UTC - 05:00 US Central
UTC - 06:00 US Mountain
UTC - 07:00 US Pacific
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