Medical Practice Setup Checklist Form
Complete this checklist to ensure your medical practice is ready to operate. Please fill out all sections related to operational setup and readiness.
Practice Name
*
Practice Type
*
Please Select
Primary Care
Specialty Care
Urgent Care
Surgical Center
Diagnostic Center
Other
Practice Location (City and State)
*
Number of Providers
*
Services to be Offered
*
General Consultation
Laboratory Testing
Imaging (e.g., X-ray, Ultrasound)
Minor Procedures
Telemedicine
Other
EHR/EMR System Status
*
Implemented and Ready
Implementation in Progress
Not Started
Scheduling System Readiness
*
Fully Set Up
Partially Set Up
Not Set Up
Insurance Participation
*
Medicare
Medicaid
Private Insurance
Self-Pay
Other
Essential Equipment Acquired
*
Exam Tables
Medical Instruments
Diagnostic Devices
IT/Computer Systems
Office Furniture
Other
Planned Launch Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Checklist
Should be Empty: