Interest Form

Home Centered Care Institute (HCCI) is seeking to identify a cohort of growth-minded home-based medical practices, geographically dispersed across Illinois, to be enrolled as members of the state’s first HCCI Practice Excellence Partner™ Network. If you are interested in having your practice participate in the Illinois House Call Project and be part of the HCCI Practice Excellence Partner™ Network in Illinois, please complete and submit the following interest form to ensure you are among the first to receive notice of the Request for Applications in early 2022.

If you have questions about Home Centered Care Institute (HCCI) or the Illinois House Call Project contact Rachel Jankowski at 630-283-9227, or RJankowski@HCCInstitute.org.

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* 1. Your Contact Information

First Name

Last Name

Credentials

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Practice Name

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* 3. Practice Type

Home-Based Primary Care (HBPC) Practice, independent

Home-Based Primary Care (HBPC) Practice, affiliated with Hospital/Health System

Office- or Clinic-based Primary Care Practice, independent, solo or group

Office- or Clinic-based Primary Care Practice, affiliated with Hospital/Health System

Hospital/Health System, without HBPC

Hospice/Community-based Palliative Care Organization, with HBPC

Hospice/Community-based Palliative Care Organization, without HBPC

Government Agency (e.g., VA, FQHC)

Other (please specify)

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* 4. Your Job Title

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* 5. Your Role in Practice/Organization

Chief Medical Officer / Medical Director

Social Worker

Chief Clinical Officer / Clinical Director

Psychologist

Nursing Executive / Director / Manager

Pharmacist

Clinical Staff – Physician

CEO / President / Executive Director

Clinical Staff – Physician Assistant

Other Executive Administrator (non-clinical)

Clinical Staff – Nurse Practitioner

Practice Manager / Operations

Medical Assistant / Nursing Assistant

Professor / Assistant or Associate Professor

Resident / Fellow

Program Officer / Director / Manager

Student / Trainee

Other (please specify)

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* 6. What goal(s) are you and your practice looking to achieve through participation in this project?

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* 7. Are you authorized to sign/submit partnership applications on behalf of your organization? Even if you are not, please still go ahead and submit this form, and watch for instructions in the application materials for demonstrating acceptance by the authorized party(ies) at your organization.