Resident Quarterly Report

TCWD Quarterly Report

Reports are due within 60 days of the end of each quarter for recipients currently in their service commitment. An email will be automatically sent to the listed practice site contact for confirmation of your employment.
Physician Name*

First NameLast Name
Physician Email*
example@example.com
Practice Site Name:*
Site Contact Email: *
Administrator, Executive, Manager, etc.
Practice Site Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year & Quarter Reporting:*
Q1: Jan-Mar, Q2: Apr-Jun, Q3: Jul-Sep, Q4: Oct-Dec
Total number of patients seen this quarter*
Patients you have seen, not total number for the practice site.
Number of TennCare patients seen this quarter*
Number of Uninsured patients seen this quarter*
Number of Medicare patients seen this quarter*
Number of Commercial Insurance & Other seen this quarter *
Optional Comments:
Leave of absence this quarter, approved location switch, etc.
By signing below, I attest that the above information is true, and the numbers reflect my current employment with the practice site listed on this report. *
Should be Empty:

TCWD Quarterly Report