Apply for Assistance

QSource and the State of Tennessee, Bureau of TennCare are combining their resources to effectively implement the new electronic health record (EHR) incentive programs created under the American Recovery and Reinvestment Act’s HITECH Act. This partnership includes the combined capture of information necessary for the State of Tennessse’s HIT regional extension center program (tnREC) and the provision of Medicaid incentive grants available to providers who achieve meaningful use of a certified electronic health record.

If you are interested in learning more either about the tnREC or Medicaid grant, please fill out the form below. Fields marked with an * are required.

Which one are you applying for: (a yes or no answer must be provide for both questions)

Medicaid incentive grants for eligible providers in Tennessee. *

Yes No

Regional Extension Center Support in adoption and meaningful use of electronic health records. *

Yes No

Contact Information:

First Name *

Title *

Last Name *

Practice Name *

Practice Type *

Address *

City *

State *

Zip Code *

Email *

Phone *

Fax *

Preferred Contact Method (Please select one) *

Provider Information

We need information for all the providers in your practice. If there are 3 providers or less in your practice, see Option 1 below. If you have 4 or more providers in your practice, see Option 2 below.

Option 1: Use this option if there are 3 providers or less in your practice. Complete the fields below for each provider.

First Provider:

First Name *

Middle Name *

Last Name *

Specialty *

NPI *

Second Provider:

First Name *

Middle Name *

Last Name *

Specialty *

NPI *

Third Provider:

First Name *

Middle Name *

Last Name *

Specialty *

NPI *

Option 2: Use this option if there are 4 or more providers in your practice. Click the link below to download the Excel document. Add your provider information to the spreadsheet and then save. Click the browse button to choose your document. The document name will be displayed in the upload box. After you complete the remaining sections of this application below and click the submit button, the document and application will be submitted. Alternately, you can email the completed Excel document to tnREC with the link below.

tnrec_physician_info.xls
File Size:	17 kb
File Type:	xls

Download File

Upload Completed Spreadsheet *

Max file size: 20MB

or Email completed spreadsheet

Assistance

I am interested in REC services. Please check all that apply:

Selection of EHR software/group purchasing of EHR software Onsite EHR implementation technical assistance Clinical reporting and functional interoperability

Onsite practice and workflow redesign Privacy and security best practices EHR staffing assistance/education I'm also interested in applying for adoption incentives availble under Medicare and Medicaid

How did you find tnREC?

How did you hear/learn about tnREC's services. Please select all that apply:

Please tell us the site or name of the publication:

Please click the button below to submit your application.

Which one are you applying for: (a yes or no answer must be provide for both questions)

Contact Information:

Provider Information

First Provider:

Second Provider:

Third Provider:

Incentives

Payer Demographics

Assistance

How did you find tnREC?