Forgot your password?
 

Questionnaire

CMIPA QUESTIONNAIRE

Thank you for your interest in Central Massachusetts Independent Physician Association, LLC (CMIPA) and for taking the time to request an application from our organization.

The current payor marketplace is moving towards requiring IPAs such as our organization to demonstrate that we are ‘clinically integrated’ among our various practices. The concept of clinical integration requires connection, communication and collaboration between our various member practices. It also requires monitoring of physician practice behavior and demonstrating that we can influence that behavior. These principles are critical to our ability to contract with payors and hospitals. The leadership of CMIPA supports this and has implemented requirements to make us clinically integrated. It is important that new members agree to participate with these clinical integration requirements.

Because of this, we are asking you to provide us with a few details about how you currently practice, and if you are willing to make changes if necessary.

Please take a minute to fill out the questionaire below. Please print the form and fax it to me at 508-438-0236, or you can submit it here. If you have any questions, please feel free to contact me at 508-438-1100.

Sincerely,

Lori Covotta
CMIPA Provider Relations

CMIPA QUESTIONNAIRE

Date of application request:

Physician’s name (First, Middle Initial, Last):

Are you joining an existing CMIPA practice?

Yes No

Are you planning to work full time?

Yes No If No, how many hours are you planning to practice?

Primary Office Location and Information:

Practice Name:

Street:

City/State/Zip:

Practice Line:

Private Line:

Fax:

Pager:

Cell Phone:

Physician’s E-Mail:

Do you regularly read your E-Mail at work?

Yes No
If No, would you be willing to use E-Mail at work? Yes No

How do you access the internet?

Dial-up Cable T-1 Other

Do you use an E-Prescribing Device?

Yes No
If yes, name of device?

If No, would you be willing to use one?

Yes No

Do you use an EMR with an E-Prescribing Module?

Yes No
If yes, name of EMR?

To become a CMIPA member, you understand that your EMR will need to be certified by the current CCHIT standard or by the standards set forth under the Health Information Technology for Economic and Clinical Health(HITECH). You also agree to interface this certified EMR to our Data Warehouse at your own expense and provide CMIPA with data that is defined by our EMR/IT Committee.

Yes, I understand these requirements

If you currently do not have an EMR, you must obtain CMIPA's preferred EMR, GE Centricity, within one year of joining the organization.

Yes, I understand these requirements and will purchase an EMR

Designation (check all that apply)

PCP
SCP
PCP & SCP

Hospital Privileges: (check all that apply)

UMass Memorial
Active
Courtesy
Not on Staff

Saint Vincent Hospital
Active
Courtesy
Not on Staff

All physicians joining CMIPA must have at SVH and at UMMHC within one year of joining. This is a mandatory requirement to become a Full Member of CMIPA for both PCPs and SCPs

Yes, I understand these requirements and will obtain privileges at both hospitals.

Other Hospitals with Privileges (Please list all):

Specialty (check all that apply)

Allergy

Anesthesiology

Dermatology

Endocrinology

Emergency Medicine

Family/Gen Practice

Gastroenterology

Hematology/Oncology

Infectious Disease

Internal Medicine

Nephrology

OB/GYN

Ophthalmology

Oral & Dental Surgery

Orthopedic Surgery

Otolaryngology

Neurology

Neurosurgery

Pathology

Pediatrics

Pediatric Surgery

Physical Medicine

Plastic Surgery

Podiatry

Pulmonary Medicine

Psychiatry

Radiology

Radiation Oncology

Rheumatology

Surgery

Urology

Other

Please List:

Are you Board Certified in the specialty above? Yes No

If No, are you Board Eligible? Yes No

Do you have an unrestricted license in the specialty above? Yes No

Network Affiliations:

Do you participate in any other network? If yes, list the other networks which you participate in:

 

     © 2010 Central Massachusetts Independent Physician Association, LLC