Epic Community Connect - Practice Intake Form

Epic Community Connect - Practice Intake Form

Thank you for your interest in Epic Community Connect. We are currently accepting applications for 2026. Please complete the form below and add any comments you feel we should know about your practice.

We appreciate you taking the time to fully complete this form.

Thank you,

Epic Community Connect Team at NewYork-Presbyterian

Your Name:*

Name of the person completing this form.

Your Email:*

Email of person completing this form.

Your Contact Number:*

Enter the best phone number where you can be reached.

Phone

Provider Name:*

Enter the provider's name for the practice you are referencing in this form.

Provider NPI:*

Enter the NPI number for the provider listed above.

Practice Name:*

Enter the official business name for the practice.

Practice Phone Number:*

Phone

Practice Fax Number:

Phone

Practice Office Address:*

If you have multiple locations, please enter the details for each location separated by a line.

Indicate Your Relationship with NewYork-Presbyterian:*

Please select a category(s) from the below based on your current status with the organization.

Voluntary Medical Staff - Providers with admitting and medical staff privileges at NYP or faculty appointments at Columbia University Medical School or Weill Cornell Medicine.

Community Based Providers - Providers who can only refer patients to New York Presbyterian and do not have admitting or medical staff privileges.

External Providers - Providers with no privileges or relationship of any kind with New York Presbyterian.

Select

Your Specialty:*

Enter the specialty of this practice (Orthopedics, Medicine, GI, etc.)

Practice Details

How many office locations are a part of your practice?*

Enter the number of office locations you have.

Are any of your office locations within New York City's 5 boroughs?*

Yes

Are any of your office locations outside of New York City?*

Yes

Please enter the other locations where you have offices:*

Annual Visit Volume:*

Enter the number of patient visits completed at your practice annually.

Annual Volume of Prescription Fills

Please enter an estimate for the number of prescription fills performed by all providers across all your sites.

How many physicians (MDs/DOs/DDS, etc.) are a part of your practice?*

How many advanced practitioners are a part of your practice?*

Enter the number of PAs and/or NPs in your practice.

Will all providers in your practice move to Epic as part of this request?*

Yes

How many non-provider staff members are at your practice location(s)?*

Enter the number of staff members in your practice (administrator, assistant, scheduling coordinator, RN, MA, etc.)

Are any procedures performed at your practice? If yes, please list them.*

e.g., Colonoscopies, Endoscopies, Biopsies, Interventional Radiology, Ablations, TEEs, Nuclear Stress Tests, etc.

Your Practice's Technology

What is the EMR and Practice Management software currently used at your practice?*

e.g., Allscripts, Athena, eCW, NextGen, paper, etc.

Do you have any existing systems you would want Epic to integrate with? If yes, please list them with the vendor and application name.*

e.g., PACS, Lab Information System, Cardiac Monitoring, ZocDoc, etc.

Do you have a dedicated IT person or team for your practice?*

Yes

How many computers are in use across your practice location(s)?*

An approximate number is ok.

How does your practice send and receive faxes today?*

eFax via the current EMR application

eFax outside of the EMR (separate application, not integrated with EMR)

Analog/Digital Fax (Fax Machine)

Not applicable

Does your practice take insurance?*

Yes

Who performs your billing today?*

Biller on Staff

External Billing Service

Are you interested in having billing functions performed in Epic?*

Select yes if you would like to learn more about Epic's billing application. Select no if you prefer to have billing performed outside of Epic (i.e., you use a third party billing service).