Clinic Profile Form - Colorado Rural Health Center

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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 State ZIP Code
County
Mailing Address (if changed in the last year and different from physical address)
Street Address Address Line 2 City 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.