M-DHAN Community Partner Registration

Contact Information

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1. Application Date:

Date

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2. First Name: (Required.)

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3. Last Name: (Required.)

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4. Credentials:

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5. Title: (Required.)

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6. Organization: (Required.)

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7. Business Address: (Required.)

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8. Business Address 2:

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9. City: (Required.)

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10. State: (Required.)

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11. Zip Code: (Required.)

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12. Email: (Required.)

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13. Business Phone Number: (Required.)

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14. Cell Phone Number: (Required.)

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15. Fax Number:

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16. How did you hear about the MD-HAN? (Required.)

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17. Are you interested in participating in any of the following M-DHAN Work Groups?

Data/Technology - (The M-DHAN Data and Technology Work Group provides expert analysis and recommendations on technology solutions in support of a coordinated healthcare delivery system.)

Primary Care Safety-Net - (The M-DHAN Primary Care Safety Net Work Group examines access issues and collaborates towards finding solutions focused on improving primary care and the local safety-net)

Community Health Worker/Patient Navigator - (The M-DHAN Community Health Worker/Patient Navigator Work Group exchanges and disseminates best practices/lessons learned throughout the Network contributing to the enhancement of service delivery among CHWs and PNs.)

Innovation/Impact - (The MD-HAN Innovation Work Group Forges key community partnership with interested participants who are focused on research, innovation and impact. The M-DHAN Impact Work Group Ensures all collaborative efforts undertaken by the Network are measurable, sustainable and have a positive impact in the health and well-being of the community.)

None of the above

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* 1. Application Date:

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* 2. First Name: (Required.)

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* 3. Last Name: (Required.)

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* 4. Credentials:

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* 5. Title: (Required.)

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* 6. Organization: (Required.)

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* 7. Business Address: (Required.)

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* 8. Business Address 2:

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* 9. City: (Required.)

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* 10. State: (Required.)

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* 11. Zip Code: (Required.)

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* 12. Email: (Required.)

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* 13. Business Phone Number: (Required.)

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* 14. Cell Phone Number: (Required.)

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* 15. Fax Number:

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* 16. How did you hear about the MD-HAN? (Required.)

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* 17. Are you interested in participating in any of the following M-DHAN Work Groups?

1. Application Date:

2. First Name: (Required.)

3. Last Name: (Required.)

4. Credentials:

5. Title: (Required.)

6. Organization: (Required.)

7. Business Address: (Required.)

8. Business Address 2:

9. City: (Required.)

10. State: (Required.)

11. Zip Code: (Required.)

12. Email: (Required.)

13. Business Phone Number: (Required.)

14. Cell Phone Number: (Required.)

15. Fax Number:

16. How did you hear about the MD-HAN? (Required.)

17. Are you interested in participating in any of the following M-DHAN Work Groups?