ACEP-SEMPA Group Questionnaire

ACEP - SEMPA Group Questionnaire banner image ACEP - SEMPA Group Questionnaire banner image

CURRENT ACEP/SEMPA Group Billing Program participants

Please enter any information that has changed in the past 6-12 months with the form below.

Required Icon= Required Form Items

Are you interested in joining one of our Group Billing Programs? Please download our ACEP and SEMPA group benefits and enrollment forms.

Download PDF Forms

ED Physician Group Information

Required IconFull Name

ACEP/SEMPA Group ID # (If applicable):

Address

City

State/Province

Postal Code

Required IconCountry

Phone

Fax

Website

Physician Assistant and Nurse Practitioner 

Do you employ Physician Assistant and Nurse Practitioner?

 

Number of Physician Assistant Employed

Who is responsible for training PA and NP?

Who is responsible for hiring and managing PA and NP?

If other, please provide additional information/contact information if different from above

Group Coordinator Information

ED Group Coordinator/Primary Contact Name

Email

Phone

Fax

Medical Director Information

Medical Director Name

Email

Phone

Fax

Hospital(s) Serviced by Group

Hospital #1

Hospital Name

State/Province

Postal Code

Hospital #2

Hospital Name

State/Province

Postal Code

Hospital #3

Hospital Name

State/Province

Postal Code

Hospital #4

Hospital Name

State/Province

Postal Code

Hospital #5

Hospital Name

State/Province

Postal Code

If you have more than 5 Hospitals to list, please email a detailed list (Name, State, Zip) to Kelley Govan or fax the list to 972.534.1579 (the fax should be to the attention of Kelly Govan). For Email attachments, we only accept PDF, Word, or Excel documents.

Please select one of the following

These questions are for internal purpose only and not for display

Group Management

 

What HER system is your hospital currently using?

 

Current/Enrolling ACEP Group Billing Participants and SEMPA 100% Club ONLY

If you have a physician, physician assistant or nurse practitioner member changes to your current participating group roster, please include the providers first and last name, ACEP or SEMPA ID (if applicable) and their email address in the fields below. If you have additional questions/requests please enter it below:

Participant #1

Full Name

Medical Title

ACEP/SEMPA ID (if applicable)

Email

Participant #2

Full Name

Medical Title

ACEP/SEMPA ID (if applicable)

Email

Participant #3

Full Name

Medical Title

ACEP/SEMPA ID (if applicable)

Email

Participant #4

Full Name

Medical Title

ACEP/SEMPA ID (if applicable)

Email

Participant #5

Full Name

Medical Title

ACEP/SEMPA ID (if applicable)

Email

If you have more than 5 participants, you will have the opportunity to attach your list on the next page after you submit this form.

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