Practice Profile Data Form

Practice Name

Practice Code (MR3 Office Use Only)

Practice Address

Address Line 1

Address Line 2

City

State

Zip Code

Practice Website

What EMR does your practice use?

What is your average panel size per physician?

NPI Number:

TPI Number:

Practice Contact 1

Email:

Business Phone:

Cell Phone:

Portal User (Yes/No)

Yes
No

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Practice Contact 2

Email:

Business Phone:

Cell Phone:

Portal User (Yes/No)

Yes
No

Practioner 1

Business Number:

Cell Phone:

Email:

NPI Number:

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Practioner 2

Business Number:

Cell Phone:

Email:

NPI Number:

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Practioner 3

Business Number:

Cell Phone:

Email:

NPI Number:

If more than three practioners to submit please upload your complete list here in Word, PDF, or Excel

Click or drag files to this area to upload. You can upload up to 3 files.

Billing Contact 1

Business Number:

Cell Phone:

Email:

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Billing Contact 2

Business Number:

Cell Phone:

Email: