TCWD Practice Site Quarterly Report
Reports are due within 60 days of the end of each quarter for recipients of the Practice Site Incentive Program funds. If funds were used to recruit or retain more than one provider, please note you will have to fill out multiple forms:
Practice Site Name (legal name of organization):
*
Practice Site Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Site Contact Name
*
First Name
Last Name
Practice Site Email Address:
*
example@example.com
Clinician Name: (Individual that was recruited/retained through this program)
*
First Name
Last Name
Clinician Email Address:
*
example@example.com
The Clinician is current working at the practice site location listed above:
*
YES
NO
Employment start date of clinician:
*
-
Month
-
Day
Year
Date
Year & Quarter Reporting: Jan-Mar (Q1), Apr-Jun (Q2), Jul-Sep (Q3), Oct-Dec (Q4)
*
(Example: 2024 Q3)
Total number of patients seen this quarter by clinician:
*
Patients seen by the recruited/retained clinician
Number of TennCare patients seen this quarter by clinician:
*
Patients seen by the recruited/retained clinician
Number of Uninsured patients seen this quarter by clinician:
*
Patients seen by the recruited/retained clinician
Number of Medicare patients seen this quarter by clinician
*
Patients seen by the recruited/retained clinician
Number of Commercial Insurance & Other seen this quarter by clinician
*
Patients seen by the recruited/retained clinician
Optional Comments:
such as leave of absence or other information that would impact the number of patients seen this quarter.
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.
*
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