Release date: June 13, 2018                  Requested By: July 11, 2018

CCN Partners are asked to express interest in participating in the Cohort Management Program through this form. For a summary of the program, click here.

The purpose of this form is for CCN to have an inventory of all interested partners and potential cohort groups.

Please Note: You do not need to fill out this form if your organization is not interested in participating in the Cohort Management Program.


Submission of this form will not obligate parties to participate if they later choose not to. 

Contact Information

Question Title

* 1. Contact Information

Which of the following best describes your organization? (Check all that apply)

Question Title

* 2. Which of the following best describes your organization? (Check all that apply)

Select the County or Region that your organization provides services to. (Check all that apply)

Question Title

* 3. Select the County or Region that your organization provides services to. (Check all that apply)

Please select all possible Cohorts of Interest. You may list cohorts not on this list in the "Other" field at the bottom. (This serves as a starting point for convening networks and does not obligate partners to participate in any of the cohorts).

Question Title

* 4. Please select all possible Cohorts of Interest. You may list cohorts not on this list in the "Other" field at the bottom. (This serves as a starting point for convening networks and does not obligate partners to participate in any of the cohorts).

What role would you play in a Network? 

Options include the following:
  • Value-Based-Payment Lead Contractor (MINIMUM REQUIREMENTS TO BE A VLC = safety-net facility + ability to flow funds to network partners + interest in contracting with an MCO + active contract with CCN for project work)
  • Tier 1 CBO: Non-profit, non-Medicaid billing, community-based social and human services organizations
  • Tier 2 CBO: Non-profit, Medicaid Billing, non-clinical service providers.
  • Tier 3 CBO: Non-profit, Medicaid billing and clinical service providers licensed by the NYS Department of Health, Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office of Alcoholism and Substance Abuse Services and independently owned primary care
  • Other: Any organization that does not meet all characteristics of the definitions above (e.g. a for-profit organization)

Question Title

* 5. What role would you play in a Network? 

Options include the following:
  • Value-Based-Payment Lead Contractor (MINIMUM REQUIREMENTS TO BE A VLC = safety-net facility + ability to flow funds to network partners + interest in contracting with an MCO + active contract with CCN for project work)
  • Tier 1 CBO: Non-profit, non-Medicaid billing, community-based social and human services organizations
  • Tier 2 CBO: Non-profit, Medicaid Billing, non-clinical service providers.
  • Tier 3 CBO: Non-profit, Medicaid billing and clinical service providers licensed by the NYS Department of Health, Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office of Alcoholism and Substance Abuse Services and independently owned primary care
  • Other: Any organization that does not meet all characteristics of the definitions above (e.g. a for-profit organization)

Please remember to RSVP to the July 13th PAC Stakeholders meeting where we will be providing more information about the Cohort Program. Click here to RSVP.

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