Community Partners Profile

We'd like to know a little more about you and your organization. Please fill out this form with as much information as possible.

Note: This form cannot be saved and edits cannot be made after submission.

If you have any questions, please contact Andrew Hibbert in the Business Development department at 909-558-3872.

Name of Organization

Primary Contact

Job Title of Primary Contact

Phone Number

Website

Total number of users who would utilize EMR system

Does your organization include ambulatory clinics?

Yes

What type of medical records system are you currently using in the ambulatory setting?

Name(s) of electronic medical records system(s) and number of years live on each

Number of ambulatory clinic visits

Does your organization include inpatient facilities?

Yes

What type of medical records system are you currently using in the inpatient setting?

Name(s) of electronic medical records system(s) and number of years live on each

Number of hospitals

Number of staffed beds per hospital (including ICU beds)

Number of admissions in which a patient is assigned to a bed

Number of inpatient days

Is your organization an academic health care organization?

Yes

We’re Stronger Together