Optimizing Team-Based Care

Optimizing Team-Based Care

Call for Applications. Please complete the form below.
Does your practice have NCQA Patient Centered Home (PCMH) recognition?*

YesNo
Application Questions (1 point each)
Practice Name*
Practice Address*
Practice Tax ID Number*
Type of Practice*
If 'Other', please specify what type of practice?
Primary contact person for this project:
Name*
Title*
Professional Credential*
Email*   Area Code*   Phone Number*
Please provide the information of the practice staff members who will be assigned to this project (maximum of 5 for Core Team):
Practice manager*
Medical provider champion*
Medical assistant*
Nurse*

If the practice has staff such as pharmacists, care managers, integrated behavioral health clinicians (IBH), they are encouraged to participate as well

Other practice staff*
If no other, just write "None"
Total number of patients in your panel*
Patient / Payer Mix
% patients insured by Medicaid*
% patients insured by Commercial/Private*
% patients uninsured*
% patients other*
Can your implementation team attend the project kick off meeting on March 20, 7:30-9am?*

YesNo
(10 points each)
Please describe your biggest challenge with working most effectively as a practice team*

Max of 500 words0/500
Please describe how your practice would benefit from participating in this project*

Max of 500 words0/500
Should be Empty:

Application Questions (1 point each)