Form CMS-10165 Electronic Health Record (EHR) Demonstration Application

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

ELECTRONIC HEALTH RECORDS (EHR) DEMONSTRATION
APPLICATION TO PARTICIPATE
The goal of the Electronic Health Records Demonstration (EHR) is to establish a 5-year pay-for-performance
demonstration project with small and medium sized primary care physician practices to promote the adoption and use
of certified EHRs to improve the quality of patient care for chronically ill Medicare patients. Doctors who meet or
exceed performance standards established by CMS will receive incentive payments for managing the care of eligible
Medicare beneficiaries. Practices incorporating greater use of health information technology into their office practices
will be eligible to earn additional incentives.
Each practice applying to participate must have a designated staff person authorized to speak for the group, provide
requested information, and to whom all correspondence will be directed. All physicians who are members of the practice
and who wish to participate in the demonstration must sign the enclosed data sharing consent form agreeing to share
data submitted to CMS and/or its contractors assisting in the implementation or evaluation of the demonstration.
Those who wish to participate should fill out this form completely. Completing this form does not guarantee
participation in the demonstration. CMS reserves the right to limit the number of practices that may participate.
For office use only

Physician Office Information
Name of Practice

1. How many physicians are part of this practice?_________________________________________________
Of these how many primarily provide primary care (general practice, family practice, gerontology,
internal medicine)? _______________________________________________________________________
2. Briefly describe your practice in terms of how it is organized, locations, services offered, affiliation with
larger networks, etc. ______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Address of primary practice location
Street Address

City

Office Number

State

Zip

Country

4. List all other locations that are part of this practice and participating in the demonstration
Office Number

Location #2 Name of Practice at this location

Street Address

City

State

Zip

Location #3 Name of Practice at this location

Country

Office Number

Street Address

City

State

Zip

Country

❏ Check here if additional locations. Attach information on additional pages
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5. Designated Contact Person
Name of Designated Contact Person

Title

Street Mailing Address (if different from primary practice location)
City

State

Telephone

E-mail

Zip

Country

6. Secondary Contact Person (if applicable, for mailing purposes)
Name of Secondary Contact Person

Title

Street Mailing Address (if different from primary practice location)
City

State

Telephone

E-mail

Zip

Country

7. Estimated number of Medicare Fee-For-Service patients that use your practice as primary source
of care
8. All incentive payments associated with the demonstration will be made to the practice and not to individual
physicians. Please provide information regarding the legal entity to which payments should be made, as
specified below.
Name of entity to which payments should be made

Street Mailing Address (if different from primary practice location)

City

Form CMS-10165

Practice Tax Identification Number

State

Zip

Country

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9. Do you have an electronic health record (EHR) in your office?
Yes ❏ (Please respond to questions that follow, and then proceed to Question #11)
If yes, what is the vendor and product?
Is this system certified by the Certification Commission for Health Information Technology (CCHIT)?
Yes ❏ No ❏ Unknown ❏
What is the date of certification?
2006 ❏ 2007 ❏ 2008 ❏

Unknown ❏

Other ❏

No ❏ (Please go to Question #10)
10. If you do not currently have an EHR, when do you plan to implement an EHR?
0–6 months? ❏ 7–12 months? ❏ 13–24 months? ❏ Other? ❏
Has an EHR product been selected?
Yes ❏ No ❏
If yes, what is the vendor and product?
Is this system certified by the Certification Commission for Health Information Technology (CCHIT)?
Yes ❏ No ❏ Unknown ❏
What is the date of certification?
2006 ❏ 2007 ❏ 2008 ❏

Unknown ❏

Other ❏

11. If you have an electronic system in your office, please describe the type of health information technology
currently used in your practice, either as part of an EHR or independently as a stand-alone product
(check all that apply):
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

Electronic patient visit notes
Electronic patient-specific problem lists
Automated patient-specific alerts and reminders
Electronic disease-specific patient registries
Clinical decision support/automated references to best practices
Patient e-mail
Patient-specific educational materials
On-line referrals to other providers
Clinical messaging with other physicians
Transmission of records to hospitals or other facilities

Laboratory tests:
❏ On-line order entry
❏ On-line results viewing
Radiology tests:
❏ On-line order entry
❏ On-line results (reports and/or digital films)
E-Prescribing:
❏ Printing and/or faxing Rx
❏ On-line Rx transmission to pharmacy
Other:
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PHYSICIANS PARTICIPATING IN THE
EHR DEMONSTRATION IN THIS PRACTICE
Practice Name

Practice Group PIN number (if applicable)

Group NPI (if applicable)

Please provide information listed in the chart below for all physicians in this practice applying to participate in
this demonstration.
Physician Name (PRINT)

Specialty

Tax
Identification
Number*

Medicare Provider
Identification
Number (PIN)
at this Location

Individual
NPI–National Provider
Identification
number

Consent Form
Attached
(Y/N)

* Provide the Tax Identification Number used by each physician when billing for Medicare services as a
member of this practice.

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CONSENT TO SHARE DATA
As an applicant to the Electronic Health Records Demonstration project, I agree to comply with the
requirements of this demonstration, including sharing all data submitted to CMS and/or its contractors
assisting in the implementation or evaluation of the demonstration.*
Provider Name (print)

Provider Signature

Medicare Provider Identification Number

Date

Individual National Provider Identifier (NPI)

Provider Name (print)

Provider Signature

Medicare Provider Identification Number

Date

Individual National Provider Identifier (NPI)

Provider Name (print)

Provider Signature

Medicare Provider Identification Number

Date

Individual National Provider Identifier (NPI)

Provider Name (print)

Date

Provider Signature

Medicare Provider Identification Number

Individual National Provider Identifier (NPI)

This form must be signed by each participating physician in the practice. If additional signatures are
necessary, please copy and submit additional signature sheets.

*

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0965. The time required to complete this information collection is estimated to average 13 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s)
or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
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