Please remember to fill out your email correctly.		Please fill out the questionnaire below to enter into a drawing for a $100 American Express Gift certificate and begin reaping the rewards of InterPro. Facility Name: * Contact Name/Title: * Phone : * Email : * Address: Type of Facility: Hospital Clinic Group Practice Surgery Ctr Radiology Rehab/Nursing Number of: Beds Physicians MT Employees   Patient Encounters / Visits per Year   Annual minutes dictated   Annual lines transcribed   Annual transcription budget Does facility currently utilize a Transcription vendor? Yes No if yes, Name of vendor Volume of work outsourced? Rate current vendor on a scale of 1-10 (1=considering terminating, 10=extremely happy) 1 2 3 4 5 6 7 8 9 10 Does current vendor interface/integrate with your HIS / MIS system? Yes No How are transcribed reports accessed and stored? Current vendor features (eSign, autofax, etc.) Current dictation system: Current transcription system: HIS / MIS system and interfaces: Plans to replace/update system: In order of importance on a 1-8 scale (1=most imp. 8=least imp.) Price 1 2 3 4 5 6 7 8 Quality 1 2 3 4 5 6 7 8 TAT 1 2 3 4 5 6 7 8 US-based Resources 1 2 3 4 5 6 7 8 Customer Service 1 2 3 4 5 6 7 8 Tech Support 1 2 3 4 5 6 7 8 Physician Satisfaction 1 2 3 4 5 6 7 8 Other 1 2 3 4 5 6 7 8 Check current challenges: Staffing (under, over, difficulty recruiting) Poor MT performance Poor quality Slow turnaround time Obsolete technology Current vendor contract expiring High MT employee costs High vendor costs Other: When do you want to improve transcription while reducing costs? Now 30 days 60 days 90 days Later