UAMSHealth.com Provider Profile Data Collection Form Last modified: October 19, 2023 You are here: Knowledge Base WordPress Content Management System Find-a-Doc Providers UAMSHealth.com Provider Profile Data Collection Form Have a UAMS Health provider or a knowledgeable stakeholder complete this form to provide the necessary information to complete a provider profile on UAMSHealth.com. UAMSHealth.com Provider Profile Data Collection Form Email Notification Do you know which Find-a-Doc editor is assigned to your service line or department? * Yes No Email Address of the Find-a-Doc Editor Assigned to Your Service Line or Department If you know who the assigned editor is, include their email address here so that they can receive the information from your form submission. Basic Information UAMS Email Address * Full First Name * Do not include just the initial. Do you have a middle name? * Yes No Full Middle Name * Do not include just the initial. Full Last Name * Include your last name as it is listed in UAMS Health Epic. Do you have a generational suffix? * Yes No Generational Suffix * Example: Jr., Sr., III Select OneJr.Sr.IIIIIIIVVVIVIIIXX Do you have a nickname that you prefer to be called? * Yes No Nickname * What is your preference for how your name is displayed? * Disregard the presence of name elements that you may not have (e.g., middle name, nickname, generational suffix). First + Middle + Nickname + Last + Suffix (e.g., Leonard Horatio “Bones” McCoy Sr.) First + Middle Initial + Nickname + Last + Suffix (e.g., Leonard H. “Bones” McCoy Sr.) First Initial + Middle + Nickname + Last + Suffix (e.g., L. Horatio “Bones” McCoy Sr.) First Initial + Middle Initial + Nickname + Last + Suffix (e.g., L. H. “Bones” McCoy Sr.) Clinical Degrees and Credentials * Select the clinical degrees and credentials that allow you to practice your form of health care in the state. Select multiple if necessary. AT Au.D. CGC CNM CNP CNS CRNA CRTT D.D.S. D.M.D. D.O. DC DPM DPT ECDS ECSPE LAC LCSW LMSW LPC LPE LPE-I LPN LSW M.D. MA O.D. OT OTA PA Ph.D. Pharm.D. PLMSW PLSW Psy.D. PT PTA QBHP RD RDA RDH RN RRT SLP None of the above OtherOther Gender * Female Male Other Languages * Afrikaans American Sign Language Arabic Azerbaijani Bengali Bulgarian Cantonese Chinese Dutch English Filipino French German Greek Gujarati Hebrew Hindi Italian Japanese Kannada Kiswahili Korean Luganda Lulamogi Lunyankole Lusoga Maithili Malay Mandarin Marathi Nepali Persian (Farsi) Polish Portuguese Punjabi Pushto Rajasthani Russian Serbian Spanish Swedish Tagalog Tamil Telugu Thai Turkish Ukrainian Urdu Vietnamese Yoruba OtherOther Have you had a studio portrait taken by UAMS Creative Services within the last 10 years? * Yes No Not sure The UAMS Creative Services photographers host sessions for UAMS Health providers to have their portrait taken for use on UAMSHealth.com and in other marketing materials. Visit https://communications.uams.edu/creative-services/kb/portrait-scheduling/ for information about how to schedule a portrait. Associated Media Is there a video on the UAMS Health YouTube channel that features you in a clinical context? Yes No Not sure YouTube Video URL * Have you been featured on the UAMS Health Talk Podcast? * Yes No Not sure Clinical Role Details Are you a resident or fellow? * Resident Fellow Neither a resident nor a fellow Are you designated by UAMS as direct patient care? * Yes No Not sure Are you designated by UAMS as a licensed independent practitioner? * Yes No Not sure Do you have a laboratory role that would make a lab coat appropriate attire? * Yes No Do you see patients via appointments? * Yes No When you see patients via appointments, how are they appointed? * Appointed to you as an individual Appointed to a general resource Are you a primary care provider? * Yes No Are you accepting new patients? * Yes No Do you require a referral for new patients? * Disregarding whether insurance may add their own requirement Yes No Do you offer second opinions? * Yes No Do you have a National Provider Identifier (NPI)? * Yes No What is your National Provider Identifier (NPI)? * Does the primary taxonomy code that is on your NPI record reflect your most specific clinical specialization? To easily look up your NPI record, visit https://npiregistry.cms.hhs.gov/search. Yes No If the primary taxonomy code that is on your NPI record does not reflect your most specific clinical specialization, follow the steps outlined at https://communications.uams.edu/web/kb/provider-titles/#not-accurate. Does the list of selected taxonomy codes on your NPI record reflect all of your clinical classifications and specializations? * To easily look up your NPI record, visit https://npiregistry.cms.hhs.gov/search. Yes No What are your other clinical classifications and specializations? For the complete list of classifications and specializations int he Health Care Provider Taxonomy code set, visit https://taxonomy.nucc.org/. Do you have an SER ID in UAMS Health Epic? * Yes No Not sure What is your SER ID in UAMS Health Epic? * Do you belong to a UAMS Health service line? * Yes No To what UAMS Health service line do you belong? * Behavioral Health Cancer Cardiovascular Diseases Core Digital Health Emergency Medicine Imaging Integrated Clinical Enterprise Integrated Medicine Lab and Pathology Musculoskeletal Neurosciences Nursing Ophthalmology Perioperative Care Services Pharmacy and Therapeutics Primary Care and Population Health Solid Organ Transplant Surgical Specialties Women and Infants OtherOther Which types of patients do you treat and/or diagnose? * Adults Children and adolescents List the conditions that you diagnose or treat * If the list would be overly long, list only those with which you wish to be associated on the website. Visual Text List the tests, procedures, exams, therapies and treatments that you perform or prescribe * If the list would be overly long, list only those with which you wish to be associated on the website. Visual Text List the locations at which you regularly practice * Be as specific as possible. Do not simply list places like “UAMS Medical Center” or “UAMS Northwest Regional Campus.” If you know the UAMS Health Epic DEP ID for each location, include in parentheses beside the name of the location. Visual Text With which hospitals are you affiliated? * UAMS Medical Center Arkansas Children’s Hospital Arkansas Children’s Northwest Arkansas State Hospital Baptist Health Medical Center-Arkadelphia Baptist Health Medical Center-Conway Baptist Health Medical Center-Heber Springs Baptist Health Medical Center-Hot Spring County Baptist Health Medical Center-Little Rock Baptist Health Medical Center-North Little Rock Baptist Health Medical Center-Stuttgart John L. McClellan Memorial Veterans’ Hospital OtherOther Patient-focused clinical biography * What information should be included in a your clinical biography when written with prospective patients in mind? What is your clinical focus? What benefits do you provide for patients or for health care at UAMS Health in general? You can write the clinical biography yourself or you can include a list of key points that should be included in your clinical biography. Do not include your education / training, your UAMS academic role, your research interests, your professional associations or your specific practice locations. Visual Text Academic Role Details Are you a member the UAMS faculty? * Yes No Do you have an academic administrative role? * Yes No Faculty Titles Faculty Title * Professor Associate Professor Assistant Professor Instructor Adjunct Professor Adjunct Associate Professor Adjunct Assistant Professor Adjunct Instructor OtherOther College (Associated With the Selected Faculty Role) * College of Health Professions College of Medicine College of Nursing College of Pharmacy College of Public Health Graduate School Academic Department / Division (Associated With the Selected Faculty Role) * Add Remove Academic Administrative Titles Academic Administrative Role Title * The academic administrative title should be distinct from the faculty title (e.g., associate professor) Dean Associate Dean Assistant Dean Department Chair Department Vice Chair Department Associate Vice Chair Department Assistant Vice Chair Division Chief Clinical Education Director Clinical Education Associate Director Clinical Education Assistant Director Fellowship Program Director Fellowship Program Associate Director Fellowship Program Assistant Director Medical Student Clerkship Director Medical Student Clerkship Associate Director Medical Student Clerkship Assistant Director Residency Program Director Residency Program Associate Director Residency Program Assistant Director OtherOther College (Associated With the Selected Academic Administrative Role) * College of Health Professions College of Medicine College of Nursing College of Pharmacy College of Public Health Graduate School Academic Department / Division (Associated With the Selected Academic Administrative Role) * Add Remove Research Role Details Are you involved in research? * Yes No Is your research role one that would make a lab coat appropriate attire? Yes No Do you have a UAMS Translational Research Institute researcher profile? * Yes No Not sure What is the URL of your UAMS Translational Research Institute researcher profile? * Find your researcher profile at https://uams-triprofiles.uams.edu/profiles/search/. Do you have a PubMed author ID? * Example: “McCoyLH” Yes No What is your PubMed author ID? * Do you have an ORCID (Open Researcher and Contributor ID)? * Yes No What is your ORCID (Open Researcher and Contributor ID)? * If you do not know your ORCID, follow these steps on the ORCID Help Center to find it. Do you have a Web of Science ResearcherID? * Yes No What is your Web of Science ResearcherID? * Education and Training Education / Training Type * Chief Residency Externship Fellowship Internship Medical School Postdoctoral Fellowship Postgraduate Education Residency Undergraduate Education OtherOther Education / Training Organization * If for a residency or fellowship, list the sponsoring institution. Education / Training Description If for a degree program, indicate the degree (and major / field of study, if relevant). If for a residency / fellowship program, list the specialty. Add Remove Miscellaneous Information Do you have any specialty or subspecialty certifications? * Yes No Are you a member of any health care professional associations? * Yes No Do any reference webpages exist that unambiguously indicate your identity? * Example: a Wikipedia article about you Yes No Not sure Specialty and Subspecialty Certifications Certifying Body * Name of Specialty / Subspecialty Certificate * Add Remove Health Care Professional Association Memberships Name of Health Care Professional Association * Add Remove Reference Webpages Include any reference webpages (e.g., Wikipedia article) that unambiguously indicate your identity. URL of Reference Webpage * Add Remove Submit If you are human, leave this field blank. Was this article helpful? Like 0 Dislike 0
