Form 0920-0234 Attachment J_Set-up Fee Questionnaire

Attachment J: Set-Up Fee Questionnaire
Form Approved
OMB No. 0920-0234
Exp. date XX/XX/20XX
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1. Please confirm contact information below:
Payee:
Attn:
Job Title:
Address:
/
City/State/ZIP Code:
Telephone Number:
Extension:
E-mail:

/

2. Please provide the total number or estimate of visits WITH EHR for your HC:
$
3.Total Set-Up Fee Issued:
4. To gauge the costs sustained by installing the National Health Care Survey EHR module, we wanted to ask what costs
your HC incurred during IG and transmission set-up and how your set-up fee was utilized:
Category
Utilized (check box)
Estimate amount of money
HC IT staff
$
EHR vendor staff
$
Installation and configuration
$
Hardware
$
Software
$
Health Information Service Provider (HISP)
$
Other: please specify below:
$

5. Did your center incur more than $10,000 worth of costs?
•

•

Total $

Yes
a. If so, how much did it cost for your center to participate?
• __________
b. If so, what was the biggest cost?
•
No

__________