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Clinic Information Sheet

    Practice Overview

    List other provider names below:

    Are there multiple clinics?

    If yes, please specify the names and addresses of other clinics below:

    Would you be interested in care alerts (hospital admit and discharge notices)?

    If yes, what email does the notice need to go to?

    EHR: (eCW, Greenway, Centricity, etc.)
    Locally Installed?
    Hosted?
    EHR Vendor Contact:

    Network

    In order to provide RGVHIE system access, please provide clinic's static IP address:

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