Description of Changes to Form_REVISEDFINAL_61708

Electronic Health Record Demonstration

Non-material Change to Approved Practice Application Form

The currently-approved practice application form for participation in the Electronic Health Records (EHR) Demonstration (OMB NO.: 0938-0965) requires two non-material modifications. The reasons for these changes, as described below, are: 1) to facilitate the processing of applications by confirming who the staff person is that completed the application; and 2) to clarify that nurse practitioners and physician assistants will be eligible for participation in the demonstration under specified circumstances.

1. Page 2 - We have added a separate component to Question 5, so there is now Question 5a and 5b. Question 5a (“Designated Contact Person”) remains unchanged. Question 5b requests contact information for the person responsible for completing the application. The reason for this change is that, while the person responsible for completing the application will likely be the same as the designated contact person, that may not always be the case. Verifying who completed the application will greatly assist the CMS contractor with any follow-up that may be necessary to confirm information and therefore facilitate the processing of the application.

2. Page 4 - On the "Physicians Participating in the EHR Demonstration in this Practice" component of the application, we clarified that nurse practitioners and physician assistants are eligible for participation in the demonstration, in addition to physicians. Specifically, we modified the sentence prior to the chart as follows: "Please provide information listed in the chart below for all physicians providers (includes nurse practitioners and physician assistants that provide primary care and bill Medicare independently) in this practice applying to participate in this demonstration”. Without this modification, it would not be clear that these providers are eligible for this demonstration, in addition to physicians.