NCMHI Innovative and Promising Practices in Pediatric Medical Home Implementation

Application Form

The National Center for Medical Home Implementation (NCMHI) is collecting promising practices and innovative models related to pediatric medical home implementation. All pediatric medical home stakeholders are eligible to apply. This includes, but is not limited to, clinicians, practices, family organizations, community-based organizations, and state agencies. Applications will be reviewed by an expert panel and selected innovative and promising practices will be published on the NCMHI Web site (www.medicalhomeinfo.org) to encourage pediatric medical home stakeholders to implement pediatric medical home at the practice, community, state, and national levels.

Instructions: Please provide the following requested information. If you prefer to complete this application in a Microsoft Word® Document, email medical_home@aap.org.:

Applicant Information

Question Title

* 1. Please provide the following information about the individual applicant:

Applicant’s Name:

Applicant’s Title:

Organization/Practice Name:

City:

State:

Email:

Question Title

* 2. May we share your contact information via our Web site?

Yes

Question Title

* 3. Which of the following best describes your organization?

Solo pediatric practice

Group pediatric practice

Hospital

Federally Qualified Health Center or Community Health Center

Academic Institution

State Department

Local, community, or non-profit organization

Family advocacy organization

Other (please specify)