CPP Application North Carolina Medical Society Foundation Community Practitioner Program COMMUNITY NEEDS QUESTIONNAIRE (To be completed by the applicant) I.Personal Information Your name Professional Status Type of Practice Name of Practice Month & Year Started Practicing Month & Year Started Practicing Current Site Practice Address City State Practice Zip Practice County Office Phone Home Phone Home Address City State Zip County Your email NC Medical Board License Number Have you ever been denied a license or have a license revoked or suspended by any professional licensing board? YesNo Have you ever been warned, censured, disciplined, had admissions monitored, had privileges limited or denied by any licensed hospital, nursing home, clinic, or managed care organization? YesNo II.Practice Information 1. Practice's Management Structure and Principal Owner(s): 2. Is this a federal, state, academic or hospital run practice? YesNo 3. List all providers and their professional status 4. Please provide historical evidence of past primary care shortages and the success or the lack thereof of previous attempts of recruiting and retaining providers. III.Practice Setting's Willingness to Improve Access for the Underserved 1.Accept Medicaid? YesNo Percentage of Practice Number of Patients? 2.Accept Medicare? YesNo Percentage of Practice Number of Patients? 3.Indigent Care? YesNo Percentage of Practice Number of Patients? 4. Describe below the practice policy for indigent care. IV.Technology and Quality 1.Does the practice have a certified Electronic Health Record or do you plan to acquire one? YesNo 2.If the practice has an EHR, are they working toward achieving Meaningful Use? YesNo 3.Does the practice have a strategic plan to obtain Patient Centered Medical Home Status? YesNo V.Evidence of Practice Viability 1. Describe the practice's night and weekend call schedule arrangements. 2.Is there a practice/business manager? YesNo Name Contact Number Email Address 3. Name(s) of similar practitioners and/or practices in the county. 4. Include any additional information you feel supports your request for financial assistance. VI.Evidence That Practitioner and Family Will Fit Into the Community 1.Will practitioner live in the community? YesNo if no, please explain below. 2.Will practitioner's spouse accept and become part of the community? YesNo if no, please explain below. 3.Will children attend local schools? YesNo if no, please explain below. 4.Will practitioner become a part of the community ? YesNo Please describe. 5. Other languages spoken? VII.Availability of other Funds for Assistance 1.What is the practitioner's salary? 2.Do owners or partners have funds to assist applicant's educational loan repayment? YesNo 3.Does local hospital have funds to assist applicant's educational loan repayment? YesNo 4.Are there income sources other than patient income? YesNo VIII.Educational Loan Information Loan amount (Undergraduate or living expense loans to not qualify.) Have you applied for state or federal education grants? YesNo Are you receiving state or federal education grants? YesNo Please Explain Signature Date Application must also include a CV and current loan data statements supporting request. *Please note that the Physicians and PA's employed by the facility you are currently working in will need to become members of the North Carolina Medical Society for you to be considered for a loan through the Community Practitioner Program.