Early Adopter Incentive Program Application

Applications must be submitted by July 31, 2018. Please complete one application per practice location.

Physician Champion Name *

Physician Champion Email Address *

Practice Name *

Physician Champion Phone Number *

Practice Address *

City *

State *

Zip Code *

Please complete all questions on the Application (Approximately 5 minutes):

How many licensed Clinicians are in your practice? *

How many patients are in your practice's patient panel? *

How many support staff are in your practice? *

Is there a person within your practice that can be the project lead? This is a staff person that will lead the program, be a reference for your staff and provide feedback to the project manager. *

How often are quality and cost conversations occurring between you and your patients? *

How often do you or your staff use quality or cost transparency tools? *

How often do you or your staff refer patients to transparency tools? *

Please list previous NYACP initatives in which you have been involved: *
(Maximum characters: 2000)
You have characters left.

Please indicate all practice transformation initiatives in which you currently participate (select multiple by holding SHIFT or CTRL): *

If Other, please list here:

Please share with us any potential concerns your practice has with this program:
(Maximum characters: 2000)
You have characters left.

Please share with us why you are interested in participating in this initiative: *
(Maximum characters: 2000)
You have characters left.

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

Early Adopter Incentive Program Application

Contact Us

Connect With Us