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HI-BRIDGE Solutions membership offers benefits including technical assistance, continuing education modules and more.

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Practice/Site Information

*Organization Name

*Organization Address Line 1

Organization Address Line 2

*City

*State

*ZIP Code

Organization Contact Information

*First Name

*Last Name

Credentials

*Position Title

*Email Address

*Phone Number

*How did you hear about GA-HITEC?

WebsiteSocial MediaBrochureWord of mouth

Organization Information

*Has your organization implemented a CMS-certified EHR?

YesNoN/A

*Can/has member provider pull(ed) a 90-day dashboard from their EHR?

Yes - continueNoN/A

*If yes, has your organization 'Attested' for 'Promoting Interoperability' under the Medicaid EHR Incentive Program?

YesNoN/A

*Can/has your organization participate(ed) in the Medicare Quality Payment Program?

YesNoN/A

*The 'Organization Contact' is authorized to enroll in HI-BRIDGE SOLUTIONS membership for of all individual providers (up-to 15) listed in the above-named practice.

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*I, the applicant for this membership warrant the truthfulness of the information provided.

*Date

Provider 1 (Please Include Providers Name, Credentials, Email and NPI Number)

Name

NPI Number

Email

Credentials

Practice Type

Additional Information

Provider 2 (Please Include Providers Name, Credentials, Email and NPI Number)

Name

NPI Number

Email

Credentials

Practice Type

Additional Information

Provider 3 (Please Include Providers Name, Credentials, Email and NPI Number)

Name

NPI Number

Email

Credentials

Practice Type

Additional Information

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