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Home
About Us
About CRHC
2023 Annual Report
Meet our Team
In the News
Employment
Contact Us
Press Releases
Membership
Renew or Join
Benefits and Options
Membership List 2024
Programs and Service Offerings
Search
Rural Connectivity
Hospital Support Services
Rural Clinics
CREATE
Information Technology
Policy and Advocacy
Group Purchasing Services
Provider Recruitment
About Colorado Provider Recruitment (CPR)
CPR For Providers
CPR For Employers
CPR Jobs
Sponsors
Organizational Sponsors
Resources
Recruitment and Retention Catalog
COVID-19
Snapshot of Rural Health
Webinar Recordings
Manuals
Coding Resources
Videos & Infographs
Maps
Rural & Frontier Preceptor Tax Credit Certification Form
Events
2024 Annual Conference
CAH Workshop
Webinars and Workshops
Safety Net Clinic Week & Videos
National Rural Health Day
2024 Forum
Career Fair
Blog
Advertise with us
Donate
Colorado Rural Health Center Clinic Profile
General Information
LEGAL Name of Clinic
*
Name Doing Business As (If different)
Type Of Practice
*
Certified Rural Health Clinic
Rural Practice
What is the date of your last Survey by the state or deeming authority?
MM slash DD slash YYYY
Is your facility a
*
Provider-Based Clinic
Independent
Not Applicable
If your facility is a provider-based clinic, what health-system or hospital are you affiliated with?
*
Please indicate if your clinic is
*
For Profit
Not for Profit
Do you offer any hours outside of normal business hours (8a - 5p, M-F)?
*
Yes
No
If yes, please list your additional hours of operation
*
Owner or CEO/ Executive Director Name
*
First
Last
Physical Address (if changed in the past year)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
Mailing Address (if changed in the last year and different from physical address)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Counties served (please choose all that apply - serviced at your facility)
*
Please choose ALL counties that patients are from that utilize services at your clinic, including the county the clinic resides in)
Adams
Alamosa
Arapahoe
Archuleta
Baca
Bent
Boulder
Broomfield
Chaffee
Cheyenne
Clear Creek
Conejos
Costilla
Crowley
Custer
Delta
Denver
Dolores
Eagle
Elbert
El Paso
Fremont
Garfield
Gilpin
Grand
Gunnison
Hinsdale
Huerfano
Jackson
Jefferson
Kiowa
Kit Carson
Lake
La Plata
Larimer
Las Animas
Lincoln
Logan
Mesa
Mineral
Moffat
Montezuma
Montrose
Morgan
Otero
Ouray
Park
Phillips
Pitkin
Prowers
Pueblo
Rio Blanco
Rio Grande
Routt
Saguache
San Juan
San Miguel
Sedgwick
Summit
Teller
Washington
Weld
Yuma
Contact Information
Primary Contact for Clinic (will be first point of contact for all general inquiries, training or funding opportunities, information requests, etc.)
*
First
Last
Title
*
Phone
*
Email
*
Clinic Manager/Supervisor (if different from primary contact)
First
Last
Title
Phone
Email
Quality (QI/QA) Contact (if applicable)
First
Last
Title
Phone
Email
HR/Recruitment Contact (providers, nursing, etc.)
First
Last
Title
Phone
Email
Additional Recruitment Staff/Contact
Medical Director
First
Last
Email
Phone
Staff
Total Number of Staff (including clinical and non-clinical)
*
Number of MD (Doctor of Medicine), DO (Doctor of Osteopathic Medicine)
Number of Dental Providers
Number of Dental Hygienist
Number of PA (Physician Assistant)
Number of FNP (Family Nurse Practitioner)
Number of RN (Registered Nurse)
Number of MA (Medical Assistant)
Number of LCSW (Licensed Clinical Social Worker)
Number of LPN (Licensed Practical Nurse)
Other CLINICAL staff
Annual Payer Mix
Percent of Medicaid
*
Medicaid (inclusive of CHIP)
Percent of Medicare
*
Percentage of Private Insurance
*
Percentage of Insured, Self-Pay
*
Percentage of Uninsured, Self-Pay
*
Number of Unique Patients in a One Year Period? (Total volume of visits)
*
Can be defined as: A patient even if seen by a provider more than once during the EHR reporting period, is only counted once in the denominator.
What EHR are you using?
*
Are you providing telehealth services in your clinic?
*
Yes
No
If yes, please provide more detail about the telehealth services you are offering
*
If no, please explain why you are not providing telehealth services
*
What, if any, quality initiatives/programs is your clinic involved in?
*
Cavity Free at Three
Patient Centered Medical Home designation
Regional Accountable Entity (RAE)
The Care Transitions Program
Clinical Quality Improvement (CQI)
Quality Payment Program (QPP)
Comprehensive Primary Care Plus (CPC+)
ACO Member
Other
None
If ACO Member, name of ACO
If "Other", what quality initiatives/programs?
Outside of primary care services, what, if any, services is your clinic providing to your patients?
*
Chronic Care Management
Transitional Care Management
Principal Care Management
Integrated Behavioral Health Care
Chronic Pain Management
Integrated Dental Services
Mental Health
Substance Use Disorder
Other
None
What type of mental health services are offered in your clinic?
Are the mental health services provided by in-house or contracted provider?
In-House Provider
Contracted Provider
Are the substance use disorder services provided by in-house or contracted provider?
In-House Provider
Contracted Provider
If "Other", what other additional services is your clinic providing?
Which of the above quality initiatives/programs and/or services is the most valuable to your clinic (top 5, list, etc.)
Anything you would like to share for our records, that is unique to your rural clinic providing primary care in your community?
Please let us know any additional ways Colorado Rural Health Center can help support your practice.
Δ
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