TCWD Psych NP Quarterly Report
Reports are due within 60 days of the end of each quarter for recipients currently in their service commitment. An automatic email will be sent to the practice site asking them to confirm your continued employment.
Name
*
First Name
Last Name
Email
*
example@example.com
Practice Site Name:
*
Site Contact Email:
*
Administrator, Executive, Manager, etc.
Practice Site Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please enter the reporting year
*
2024, 2025, 2026, etc.
Please select the reporting quarter:
*
Q1 (Jan-Mar)
Q2 (Apr-Jun)
Q3 (Jul-Sep)
Q4 (Oct-Dec)
Total number of patients seen this quarter
*
Patients YOU have seen, not the 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 or Other patients 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.
*
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