Practice Information

Practice name*

Practice address*

Practice phone*

Which EHR do you use?*

Do you have a lease?*

NoYes

Leaseholder name*

Leaseholder contact info *

Phone

Email

What company covers your malpractice insurance?*

Please provide your malpractice policy number *

Does anyone assist you with administering your practice (eg scheduling, billing, insurance submission)? *

NoYes

Assistant's name *

Assistant contact info *

Phone

Email

Are you part of a group practice?*

NoYes

Do you have an attorney who will be involved in handling your affairs in the event of your death or incapacitation?*

NoYes

Do you have paper medical records?*

NoYes

Please describe what is contained in those recordsNote: We do not take custody or responsibility of physical files but we can advise your personal representative in how to store them, and we can act as intermediaries for transfer of records.

2. Practice Information

Phone

Email

Phone

Email