First Name

Last Name

Work Email

Work Phone

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Company

Job Title

Are you a current Qualifacts customer? Yes No

Total number of providers?

Current EHR?

What is the primary service your agency provides? Adoption & Foster Care Adult Day Care Adult Rehabilitative Applied Behavioral Analysis (ABA) Autism Spectrum Disorder Billing Services Case Management Certified Community Behavioral Health Clinics Child Welfare Community Behavioral Health Center Correctional Health County Health Department County Mental Health Department Court Ordered Services Group Home Group Therapy Home Health Care Homeless Services Individual/Family Therapy, Counseling Intellectual & Developmental Disability (IDD) Intensive Outpatient Program (IOP) Medication Management Methadone Clinic Occupational Therapy Partial Hospitalization Program (PHP) Pediatric Rehabilitative Pediatrics Physical Therapy Prescribed Pediatric Extended Care (PPEC) Primary Care Psychiatric Hospital Psychiatric Rehabilitation Program (PRP) Psychiatry Psychology Public Health Department Residential Treatment Center (RTC) Skilled Nursing Speech Therapy Substance Abuse Support Services TMS - Transcranial Magnetic Stimulation Veterans Affairs Victim Services Vocational Services

What services would you like us to review during your demo? Electronic Health RecordsRevenue Cycle Management/BillingVirtual Care/TelehealthBusiness Intelligence and AnalyticsArtificial IntelligenceOther Services

What services would you like us to review during your demo? Business IntelligenceRevenue Cycle ManagementCredentialing ServicesVirtual Care with Patient PortalArtificial IntelligenceASAM Criteria SoftwareCustomer Success Consulting & TrainingEnhanced Support ServicesReport Writing ServicesIntegration Services

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