NERVES Membership Application


Name________________________________________ Title___________

Practice__________________________________________________________

AANS/CNS Physician Member _______________________________________

Address__________________________________________________________

City, State, Zip_____________________________________________________

Phone________________________________ Fax_______________________

E-mail___________________________________________________________


Attach check for $175 made payable to NERVES and mail to:

Lisa Beebe
c/o The University of Texas Health Science Center At San Antonio
Department of Neurosurgery
7703 Floyd Curl Drive - MC 7843
San Antonio, Texas 78229-3900


Amount Enclosed _______________________ Check # __________________

List all practicing clinicians in your practice (attach letterhead)
_________________________________________________________
_________________________________________________________
_________________________________________________________


Please indicate the total number of clinicians in your practice:

Neurosurgeons ________        full-time ____ part-time

Neurologists __________        full-time ____ part-time

Physiatrists ___________        full-time ____ part-time

Anesthesiologists _______       full-time ____ part-time

Physician assistants _____       full-time ____ part-time

Nurse practitioners ______      full-time ____ part-time


Please indicate the ancillary services provided in your facility:

___ MRI Scanner

___ CT Scanner

___ Ambulatory Surgery

___ Physical Rehabilitation

Other ___________________

Which practice managment software do you use?
_____    Medical Manager
_____    MISYS (Medic)
_____    IDX
_____    Other __________________________

Do you do your transcription:
_____    In-house
_____    Outsourced
_____    EMR

If outsourced or using an EMR package, which vendor do you use?
______________________________________________________

Are you doing electronic prescriptions? _______________________

What are the top four managed care organizations in your area?
__________________________________
__________________________________
__________________________________
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