Main content

    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


























    Practice Panel Size (all physicians combined):

    OR, if 18 months data not available,

    Please obtain the most accurate data possible. In most cases, this will come from your biller.


    Open to New Patients?

    Plan to expand practice/recruit new physicians within the next five years?

    Medi-Cal Population:

    EHR currently in place? -

    Physician EHR Lead identified?