PPRNet Membership Application 

Thank you for your interest in PPRNet.  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       

Practice Address       

City       State        Zip   

Practice Phone Number    

Practice Fax Number   

Contact Name   

Contact Email Address    

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

When did your practice start using Patient Records (must be using at least 6 months)?    (year)

What version of Patient Records do you currently use?   9 8  Other 

What percentage of the patients that you have seen since you started using Patient Records are registered in Patient Records? 100% 90% 80% Less than 75% None     

What percent of your office visits are recorded in Patient Records 100% 90% 80% Less than 75% None     
(I know that some physicians don’t enter all of their notes in the system, for example, their psychiatric notes)

What percent of diagnoses are entered so that the Problem List/Diagnosis List is updated?  100% 90% 80% Less than 75%     
(Either through direct entry or using the .MP, .OP, DX, or T line)

What percent of your prescriptions are entered so that the Medication List is updated?   100% 90% 80% Less than 75% None   

What percent of laboratory results are entered into the Lab section of Patient Records?   100% 90% 80% 70% 60% 50% Less than 50% None   

What percent of Health Maintenance are entered into the HM section of Patient Records?  100% 90% 80% 70% 60% 50% Less than 50% None    

Number of Providers in your practice   

Provider 1: Name    Degree MD DO NP PA   Provider Code*  
                                                                                                                 *3 letter/3 digit Usual Provider Code to assign patients to a provider

Race White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race    Ethnicity Hispanic or Latino Not-Hispanic or Latino   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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race    Ethnicity Not-Hispanic or Latino Hispanic or Latino     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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino  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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino   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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino   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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino    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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino 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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino    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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race  Ethnicity Not-Hispanic or Latino Hispanic or Latino     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 White Black American Indian Alaska Native Asian Native Hawaiian Pacific Islander Some Other Race   Ethnicity Not-Hispanic or Latino Hispanic or Latino   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

*Required