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EHR Donation Program Application Form

EHR Donation Program Home

Eligibility for the California Pacific Medical Center EHR Donation Program is contingent upon all physicians in the practice applying being members of either the California Pacific or the St. Lukes medical staff. Please do not complete this application if one or more of the physicians in your practices do not meet this criteria.

Practice application and notification process:

1. EHR Donation Program application submitted


2. Implementation schedule submitted to BTPSO


3. Application reviewed for completeness


4. California Pacific Administration review of recommended implementation schedule


5. Advisory Committee review of monthly applicant pool, recommendation of implementation schedule


6. Practice notified of implementation date options


7. Contracts signed and deposit submitted

BTPSO Technical Assessment takes place during steps 3-5

Application Form

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Practice Name:

Location(s):


Phone Numbers:


Specialties:

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Physician Name 1:
Physician Name 2:
Physician Name 3:
Physician Name 4:
Physician Name 5:
Physician Name 6:
Physician Name 7:
Physician Name 8:
Physician Name 9:
Physician Name 10:
Practice Manager Name:

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Practice Panel Size (all physicians combined):
Defined by the number of unique individual patients (not total visits) seen during the last 18 months:
OR, if 18 months data not available,
Number of unique individual patients seen per month:
Please obtain the most accurate data possible. In most cases, this will come from your biller.

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Open to New Patients? Yes No

Plan to expand practice/recruit new physicians within the next five years? Yes No

Medi-Cal Population: Less than 3% Between 3 and 6% Greater than 6%

EHR currently in place? Yes No - If Yes, vendor name:

Physician EHR Lead identified? Yes No - If so, name:

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Your Email Date Application Completed: