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Provider Demographics

Include all providers employed by the practice for the full fiscal year indicated in the Practice
Demographics section, as well as any new hires during the same fiscal year. Providers that left the
practice during the fiscal year may be included, but you must select the corresponding employment
status. Providers that did not work at all during the fiscal year should not be included. Enter each
provider on a separate row; do not group multiple providers together on the same line.

 

*Provider Name

Enter a unique name, ID, or tracking code for each provider. This may be the provider’s actual name, initials, NPI, last four numbers of SSN, or an internal code used to identify the provider. If we have questions on your submission, we will refer to your providers by the name entered here.

 

*Employment Status

New hire: The provider was hired by the practice during the reported fiscal year.
Actively employed: The provider was employed for the full reported fiscal year. If the provider was
hired during the reported fiscal year, but is not expected to begin work until the next fiscal year, do
not enter the provider on this survey.
Furloughed: The provider was furloughed during the reported fiscal year. A furlough is a temporary,
yet mandatory, leave of absence in which the provider is expected to return to work at a future date.
No longer employed: If the provider left the practice, for any reason during the reported fiscal year.
Locum tenens: The provider is temporary or they are hired to fill a spot for a temporary period of
time during the reported fiscal year.

 

Provider NPI

Indicate the provider's National Provider Identifier (NPI), which is 10 digits in length. If you do not know your provider’s NPI number, you can find it on the following link: https://npiregistry.cms.hhs.gov/

 

*Physician Specialty

Select only one specialty for each physician using the specialties listed in the dropdown provided. A physician should be classified in the specialty or subspecialty where he or she spends more than 50 percent of their time.

NOTE: If the appropriate subspecialty is not available in the drop-down list, please select the main
specialty or "Other Physician Specialty (please specify)" and type the subspecialty in the "Other
Physician Specialty" column.

*** Choose either a physician specialty OR an advanced practice provider specialty for each
provider entered. Do not enter a value for both columns on the same row ***

 

*Advanced Practice Provider Specialty

Select only one specialty for each advanced practice provider using the specialties listed in
the dropdown provided. An advanced practice provider should be classified in the specialty or
subspecialty where he or she spends more than 50 percent of their time.

NOTE: If the appropriate subspecialty is not available in the drop-down list, please select the main
specialty or "Other Specialty (please specify)" and write-in the subspecialty in the "Other APP
Specialty" column.

*** Choose either a physician specialty OR an advanced practice provider specialty for each
provider entered. Do not enter a value for both columns on the same row ***

 

*Provider Rank

Select the applicable provider status from the dropdown options, including:
Non-Academic Provider: A clinical provider in a non-academic organization.
Non-Faculty Academic Provider: A clinical provider in an academic organization, who isn't faculty/ doesn't teach.
Instructor: An academic provider who teaches (a non-tenure-track).
Assistant Professor: An academic provider who assists with teaching, usually immediately below an associate professor.
Associate Professor: An academic provider who teaches, usually a mid-level ranked faculty member.
Professor: An academic provider who teaches, usually the highest ranking faculty member.
Division Chair/Chief: An academic provider who serves as head of a division.
Department Chair: An academic provider who serves as head of the department.
Other: Provide a rank not listed above.

Provider Gender

Report the gender for which each individual provider identifies with by choosing “Male” or “Female”
from the drop-down provided. If you do not wish to provide this information, select "Prefer not to
Answer".

 

*Type of On-Call Coverage Provided

Select the type of call that most closely describes what was provided by the provider.
No Call Provided: If the provider does not take call, select "No Call Provided"
Restricted: A type of on-call coverage in which the provider must be present at the facility
throughout the additional block.
Unrestricted: A type of on-call coverage in which the provider must be available to respond to
pages as necessary. Also referred to as "beeper only" coverage.
Both Restricted/Unrestricted: A type of on-call coverage in which the provider must be present at
the facility for part of the additional block and is available to respond to pages, as necessary, for the
other part of his or her coverage.
Trauma Call—Level 1: The provider must only be available for emergency trauma call while providing on-call coverage.
Trauma Call—Level 2: The provider must only be available for emergency trauma call while
providing on-call coverage.
Trauma Call—Level 3: The provider must only be available for emergency trauma call while
providing on-call coverage.
Trauma Call—Level 4: The provider must only be available for emergency trauma call while
providing on-call coverage.
General ED Call: The provider must only be available for general emergency department call while
providing on-call coverage.
Other Call: The provider must provide a type of coverage other than those listed above, please
describe.

 

*Provider had Medical Directorship Duties

Answer “Yes” if the provider had medical directorship duties.

 

Type of Compensation Tax Form

Select the form (W2, K1, 1099) you use to report employee wages.

 

Years in Specialty

Report the number of years each physician or advanced practice provider has practiced in the
specialty reported. The number of years should begin when the physician completed their residency
or fellowship.

 

Years in Specialty

Answer “Yes” if the provider performed telehealth services.
 

PROVIDER PERFORMED TELEHEALTH SERVICES

Answer “yes” if the provider performed telehealth services.
 

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