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NJAFP DSME/DPP How-To Guide
How-To Guide Enrollment Form
1.
Practice Information
Practice Name
Street
City
State
Zip
Name of ACO (if applicable)
Name of EHR system (if applicable)
2.
Type of practice
Solo practice
Group practice
FQHC
Other (please specify)
3.
Program Contact
Name
Title
Email
Phone
4.
How did you hear about this program?
Email
E-newsletter
NJAFP Journal "Perspectives"
Colleague
Other (please specify)
5.
How would you like to engage in this program?
CARBS How-to Guide only
CARBS How-to Guide and Coaching Support
Unsure/Other (please specify)
