Atlantic Alliance Practice Assessment Survey

Welcome to the Alliance, Basic Practice Information

Thank you for deciding to explore opportunities within the Atlantic Alliance, an established Clinically Integrated Network that comprises over 2,500 providers in a variety of contractual arrangements around shared savings and value based care.

While the following survey is focused on Primary Care Practices, if you are a specialist, we invite you to become part of our PCP medical neighborhoods by working closely with us within our CIN, where you will have opportunities for shared savings, and specialist focused programs such as bundles and episodes of care. So please fill out the survey.

To help us match you with the best contractual programs within the Alliance, please fill out the following survey as completely as possible. The more information we have , the more likely we can match your practice to participation in successful contracts.

Question Title

* 1. Practice or Group Legal Name

Question Title

* 2. Practice or Group Main Office Information

Street 1

Street 2

City

State

Zip Code

Phone

Fax

Question Title

* 3. Other Practice Site Names or Locations Within Group?

Site 1 Name and Location

Site 2 Name and Location

Site 3 Name and Location

Site 4 Name and Location

Site 5 Name and Location

Question Title

* 4. Main Contacts

PHYSICIAN MANAGER

Phone Number

email address

OFFICE MANAGER

Phone Number

email address

Question Title

* 5. Please indicate if you function primarily as a primary care provider (PCP) or a specialist care provider (SCP)

PCP

SCP

BOTH with PCP focus

BOTH with SCP focus

Question Title

* 1. Practice or Group Legal Name

Question Title

* 2. Practice or Group Main Office Information

Question Title

* 3. Other Practice Site Names or Locations Within Group?

Question Title

* 4. Main Contacts

Question Title

* 5. Please indicate if you function primarily as a primary care provider (PCP) or a specialist care provider (SCP)

Question Title

* 6. If a specialist, please enter your primary specialty