PPRNet Membership Registration Form 

Membership Registration is Free.  Please answer the following questions and then click on the Submit button to send your information to the PPRNet office.  Please remember to include Patient Record Usual Provider Codes on each provider in your practice.  

Medical Director           

Medical Director Email Address:

Practice Address     

City           State            Zip 

Practice Phone Number                 Practice Fax Number    

Contact Name                                   Contact Email Address  

Practice Specialty                Family Practice Internal Medicine Multi Other                         If "Other" Please State   

Which Electronic Health Record (EHR) are you using?     Lytec MediSoft Practice Partner

Approximately when did your practice start using McKesson's EHR?    (Month/Year)

What version of the EHR do you currently use?   

How did you hear about PPRNet?  

Provider 1:

Name     Degree MD DO NP PA    Provider Code*  *3 letter/3 digit Usual Provider Code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race       Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer    Sex Male Female     DOB      

Approximate number of patients seen per week

Provider 2:

Name     Degree MD DO NP PA     Provider Code*  *3 letter/ 3 digit Usual Provider Code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race       Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer    Sex Male Female     DOB

Approximate number of patients seen per week                                     

Provider 3:

Name     Degree MD DO NP PA     Provider Code*  *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race       Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer      Sex Male Female     DOB

Approximate number of patients seen per week                                 

Provider 4:

Name     Degree MD DO NP PA     Provider Code*   *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer       Sex Male Female     DOB 

Approximate number of patients seen per week                                           

Provider 5:

Name    Degree MD DO NP PA      Provider Code*  *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer     Sex Male Female      DOB 

Approximate number of patients seen per week                                          

Provider 6:

Name    Degree MD DO NP PA     Provider Code*  *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race     Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer      Sex Male Female     DOB 

Approximate number of patients seen per week        

Provider 7:

Name     Degree  MD DO NP PA     Provider Code*  *3 letter/3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer     Sex Male Female      DOB 

Approximate number of patients seen per week                                                   

Provider 8:

Name     Degree MD DO NP PA     Provider Code*  *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer     Sex Male Female      DOB 

Approximate number of patients seen per week                                              

Provider 9:

Name     Degree  MD DO NP PA    Provider Code*  *3 letter/ 3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer     Sex Male Female     DOB

Approximate number of patients seen per week                                                   

Provider 10:

Name     Degree MD DO NP PA     Provider Code*  *3 letter/3 digit usual provider code to assign patients to a provider

Race Select From the List Below Prefer Not to Answer White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race      Ethnicity Not-Hispanic or Latino Hispanic or Latino Prefer Not to Answer     Sex Male Female     DOB

Approximate number of patients seen per week                                           

For additional providers, please submit more than one form.  This is form  1 of 1 2 of 2 3 of 3 more than 3

Person filling out this form:     

Your role in the practice:       

Your contact information:    

*Please be sure all required information is filled out.