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 *

Email *

Website *

Total number of users who would utilize EMR system *

Does your organization include ambulatory clinics? *

Yes

No

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

No

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

No

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