2020 Gateway Health GPE Provider Incentive Program Acknowledgement of Agreement.

Please do not use the Back Button when completing the Acknowledgement.
This Agreement is for the 2020 Gateway Health GPE Program. 

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* 1. Please enter the name of your Health System, Organization, or Entity that your group or practice operates with.

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* 2. Please enter the Taxpayer Identification Numbers (TIN) that are associated with your Health System, Organization, or Entity.  NUMBERS ONLY.
Contact your Clinical Transformation Consultant at ProviderEngagementTeam@gatewayhealthplan.com with questions on finding your TIN.

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* 3. Please enter your first name.

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* 4. Please enter your last name.

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* 5. Please enter your professional email address.

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* 6. Please enter your title.

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* 7. Please enter the name of your CTC or Provider Account Liaison, if known.

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* 8. I acknowledge receipt of the 2020 Gateway Health GPE Program Manual. I agree that I had an opportunity to review and ask questions about the Program, and I understand the payment schedule, scoring methodology and Program requirements. I agree to participate in the Program, comply with the Program requirements and accept Gateway’s determination of my incentive payment. Upon request from Gateway, I agree to meet with a Gateway Clinical Transformation Consultant once during the first quarter to provide an education session to my providers and staff and quarterly thereafter during the 2020 program year. I understand that Gateway has the discretion to amend the Program term and/or terminate my participation in the Program at any time.

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