Outpatient Settings - Kentucky REC.xls by shensengvf

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									                                            Want to submit this form electronically? Contact: KYREC@uky.edu



Practice and Location Data Worksheet
A. Hospital Information                                                    B. Patient Demographics by Unique Patients
 Hospital Name (legal business name)                                     Instructions: Please provide estimates for the requested information in this
 Tax ID                                                                  section. Patient Encounters refers to the estimated total number of VISITS in
 Address                                                                 one year (ex. If the same patient visits multiple times, you would count each
 City                                                                    visit). Unique Patients refer to the estimates total number of PATIENTS in one
 County                                                                  year (ex. if the same patient visits multiple times, you would only count them
 State                                                                   once).
 Zip Code                                                                  1. # of Patient Encounters per Year:
 Main Phone                                                                2. # of Unique Patients per Year:
 # of Support Staff:                                                       3. Percent of Medicaid Patients per Year:
 Existing EHR System & Version                                             4. Percent of Medicare Patients per Year:
                                                                           5. Percent of Private Insurance Patients per Year:
Primary Care Clinics (PCCs):                                               6. Percent of Uninsured Patients per Year:
  # of Hospital owned PCCs                                               C. Patient Demographics by Inpatient Bed Days
  # of Hospital affiliated PCCs                                          Instructions: All of this data is by Inpatient Bed Days. More specifically, this is
  # of MDs and ARNPs for each PCC                                        the sum of the Length-of-Stay for all inpatient encounters in a year by payer as
                                                                         well as total inpatient days. This is used to calculate EHR Incentive Payments
                                                                         and is NOT REQUIRED at time of executing the Agreement with the Kentucky
                                                                         REC. This is to help set the expectations for the hospital in preparation for
                                                                         Registration & Attestation.
                                                                           1. # of Total Inpatient Bed Days per Year:                                      0
                                                                           2. # of Medicaid Inpatient Days (w/o KCHIP) per Yr:
                                                                           3. # of Medicare Part A Inpatient Days per Year:
                                                                           4. # of Medicare Part C Inpatient Days per Year:
                                                                           5. # of Private Insurance Inpatient Days per Year:
                                                                           6. # of Uninsured Inpatient Days per Year:
                                                                           7. # of KCHIP Inpatient Days per Year:
NOTE: Please list Outpatient Setting Location Information in the subsequent tab below. If your hospital has multiple Outpatient Locations, please list
them all on the next tab. Be sure to include the addresses, phone numbers, Tax IDs, and NPIs of those additional locations.




Version: 2                         Additional Questions? Call Toll free at: 888-KY-REC-EHR or email at: KYREC@uky.edu
                                                                Exhibit C - Hospital Data
                                           Want to submit this form electronically? Contact: KYREC@uky.edu


Outpatient Setting Location Information
Instructions: Please include all outpatient settings that are owned by this hospital. If the Tax ID and/or the NPI for these locations is the same
as the hospital, then just indicate "Same" in the respective field.
Location Name                         Tax ID        Address                                City                     State Zip        NPI




                                  Additional Questions? Call Toll free at: 888-KY-REC-EHR or email at: KYREC@uky.edu

								
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