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 Name
Last 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
City
State / Province
Postal / Zip Code
Year & Quarter Reporting:
*
Please Select
2025 Q3
2025 Q4
2026 Q1
2026 Q2
2026 Q3
2026 Q4
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.
*
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