Section 1 Instructions

Thank you for using the Medical Equipment Utilization Survey online submission form. To complete the form, enter the requested data in the form below and click the "Submit Data" button. When your information has been successfully submitted, you will receive a confirmation message, a copy of the data you entered, and directions on how to proceed to Section 2 of the form.

Click here for CPT Codes (Opens new window)

If you have problems or questions, call or e-mail Alecia Craighead, Staistical Analyst, at 615-253-2782, alecia.l.craighead@tn.gov.

Note: If you have previously completed Section 1 and are returning to complete Section 2, click here to go directly to Section 2.

* Required Fields

Contact Information

Facility:
Facility:
(If not included in the list above.)
County: *
Contact Name: *
Contact Email: *
Contact Phone: *

Reporting Period

From: *    *
To: *    *

Medical Equipment Data

Equipment # Units Mobile Days/Week Utilization Medicare TennCare/ Medicaid Private/ Commercial Insurance Private/Self-Pay Charity Care Bad Debt Other Total
CT
(Fixed Units)
Procedures
Gross Charges
CT
(Mobile Units)
Procedures
Gross Charges
Linear Accelerator
Procedures
Gross Charges
Cyberknife
Procedures
Gross Charges
Gamma Knife
Procedures
Gross Charges
MRI
(Fixed Units)
Procedures
Gross Charges
MRI
(Mobile Units)
Procedures
Gross Charges
MRI
(Pediatric)
Procedures
Gross Charges
PET
(Fixed Units)
Procedures
Gross Charges
PET
(Mobile Units)
Procedures
Gross Charges