NJAFP Garden Practice Transformation Network - Information Request

Thank you for your interest!

Please provide your practice and contact information below, and one of NJAFP's Healthcare Transformation Coaches will contact you with more information about the free coaching services you may be eligible for!

Question Title

* 1. Practice Information

Practice Name

Primary Site Location

Practice Contact Name

Contact Email

Contact Phone

Number of Practice Locations

Number of Providers

Question Title

* 2. Practice Type

Primary Care (Adolescent Medicine, Family Practice, General Practice, Geriatrics, Internal Medicine, Pediatrics)

Other (please specify)

Question Title

* 3. Is the practice a member of the following (check all that apply):

	Yes	No	N/A
MSSP ACO	MSSP ACO Yes	MSSP ACO No	MSSP ACO N/A
Medicaid ACO	Medicaid ACO Yes	Medicaid ACO No	Medicaid ACO N/A
Commercial ACO	Commercial ACO Yes	Commercial ACO No	Commercial ACO N/A
CPCi or applied for CPC+	CPCi or applied for CPC+ Yes	CPCi or applied for CPC+ No	CPCi or applied for CPC+ N/A

Other (please specify)

Question Title

* 4. Preferred Method of Contact

Telephone

Other (please specify)