Wisconsin Health Information Technology Extension Center

Wisconsin Health Information Technology Extension Center
 

Application to Participate

The Wisconsin Health Information Technology Extension Center (WHITEC) provides education, outreach, and technical assistance to Wisconsin health care providers in selecting, implementing, and using health information technology to improve the quality and value of health care.

If you wish to apply to work with WHITEC on HIT adoption and meaningful use, please review and complete the following online application, or download a PDF of the application.

For questions or additional information, please contact:

Ashley Green
Education and Outreach Coordinator
agreen@whitec.org or (608) 729-2705

Note:  Vendor inquires should be directed to Chris Becker at cbecker@metastar.com or (608) 395-9820.


Practice Name

Practice Address		  
  City		  
  State		  
  Zip Code

Practice Phone Number

Name of Authorized Representative

Title

Email Address
Are you affiliated with a hospital(s)?      Yes   No
      If yes, please list:
Do you have multiple clinic sites?      Yes   No
      If yes, how many?
Are you a Federally Qualified Health Center?      Yes   No
Are you a Critical Access Hospital?      Yes   No
Are you a Rural Hospital with less than 50 beds?      Yes   No
Do you plan to apply for either of these Meaningful Use incentives?     Medicare   Medicaid   Unsure
      If yes, by when:
Number of primary care* physicians in the practice: 
Number of primary care* mid-level providers (PA, NP) in the practice: 
      *Primary care is defined as Family Practice, Internal Medicine, OB/GYN, and Pediatrics
Number of other specialty physicians in the practice: 
Number of specialty mid-level providers (PA, NP) in the practice: 
      Please list the specialties the practice would represent: 
Current Status:
Are you currently using an Electronic Practice Management System?   Yes   No
      If yes, list product name and date of implementation:
Do you anticipate a need to replace your practice management system prior to or at the time of
implementing an EHR?   Yes   No
Are you currently using an Electronic Health Record (EHR)?   Yes   No
      If yes, list product name, version and date of implementation: 
Have you purchased an EHR, but have yet to implement?   Yes   No
      If yes, list product name and anticipated date of implementation: 
      If no, when do you plan to purchase an EHR?    implement an EHR?
Are you currently reporting to PQRI?   Yes   No
Are you currently reporting for other initiatives?   Yes   No
      If yes, please list:  
How did you hear about WHITEC?
       Mailing    Conference    Website    Other