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North State Health Connect HIE Survey

1. Practice Information

Question Title

* 1. Please enter your name, practice/organization name, and contact information below for tracking purposes and follow up questions only.

NOTE: This information will NOT be distributed and will not appear on the final report.

Contact Name:

Practice Name: *

Email Address: *

Phone Number:

Question Title

* 2. What is your organization's primary practice area or specialty?

Question Title

* 3. How many medical providers do you have in your practice?

Note: A medical provider is any Doctor (MD, DO, DDS, OD, etc.), Physician's Assistant (PA) or Nurse Practitioner (NP) who independently sees patients.