Medical Organization Information Request
To help us understand your organization/system and to prepare for our initial meeting, please provide us the following information regarding your organization/system
Date
*
-
Month
-
Day
Year
Date
Organization Name
*
Total Number of Locations
*
Preferred Contact Name
*
First Name
Last Name
Contact Title
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred way(s) to be contacted/updated
Email
Telephone
Zoom Call
Other
Best time to contact
8-10 am
10 am - noon
1 pm - 2:30 pm
2:30 pm - 5:30 pm
Other
Back
Next
Organization/System Information
Number of primary care providers in your organization/system
*
Number is
*
Estimated
Current Number
Average of Past Year
How many Medicare patients does your system serve?
*
Number is
*
Estimated
Current Number
Average of Past Year
How many of those Medicare patients are Traditonal Medicare patients?
*
Number is
*
Estimated
Current Number
Average of Past Year
How many of those Medicare patients are Medicare Advantage patients?
*
Number is
*
Estimated
Current Number
Average of Past Year
Is your organization/system a Federally Qualified Health Center?
*
Yes
No
Is your organization/system member of an Accountable Care Organization?
*
Yes
No
What is the name of the ACO?
Additional Information, if helpful
Submit
Should be Empty: