ACO Provider Scheduling Parameters

ACO Name:

Practice Name:

Provider Names:

Additional Providers:

Address: , ,

Phone:

Consultant:

Tax ID:

NPI: All NPI Numbers Under This TIN

Name:

Position:

Phone:

Email:

Fax:

EMR:

Remote EMR Access: Yes

Vetting Required: No

• awv: No
• dropped: No
• idc10: No
• atRisk: No
• medicare: No
• commercial: No
• both: No

Permit to Call & Schedule: Yes

Prominence Patients: No

Text Patients: Yes

Contact via EMR: No

No Contact Years:

Indicator Notes:

Special Notes:

Visit Time Allotment:

Max Visits/Day:

Bloodwork Required: No

In-House or Outside:

Advanced Time for Bloodwork:

Schedules Bloodwork: No

Fasting Required: No

Fasting Duration (hrs): 0

Change Appt to Wellness: No

Exceptions:

Follow-up Time:

Same Day Appts: No

Telehealth: No

Telehealth Time Allotment:

Time Zone:

Time Zone:

Multiple Offices: No

Additional comments for AWV scheduling:

Time Zone:

Time Alloted for Post Discharge Visits:

Necessary Information for Post Discharge Visits:

PDV EMR Appointment Type:

Nurse Navigator Program: No

Additional Comments for PDV:

Credentials: Not selected

By clicking "Submit", you confirm that the information provided is accurate and complete. You also agree to the terms and conditions of the Provider Scheduling Parameters.

*If no time slots are available within the post discharge window double booking will be required.*

Patients should be scheduled ASAP, scheduling within 2 days is better than 7 - 14 days when trying to prevent readmission.

This process is worked in collaboration with the practice, please continue to check your alerts! Parameters will be active for 1 year from date signed unless a written request to change is provided.