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2. Practice Information
Practice name*
Practice address*
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Practice phone*
Which EHR do you use?*
Do you have a lease?*
No
Yes
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)? *
No
Yes
Assistant's name *
Assistant contact info *
Phone
Email
Are you part of a group practice?*
No
Yes
Do you have an attorney who will be involved in handling your affairs in the event of your death or incapacitation?*
No
Yes
Do you have paper medical records?*
No
Yes
Please describe what is contained in those records
Note: 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.
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EDIT: Licensure Info
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