ACP Advance Chronic Pain QI Program Application
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1.
First name
(Required.)
*
2.
Last name
(Required.)
*
3.
Practice name
(Required.)
*
4.
Email address
(Required.)
5.
Phone number
*
6.
City
(Required.)
*
7.
State
(Required.)
8.
Do you have support from senior leadership in your organization to participate in the ACP's Chronic Pain QI initiative?
Yes (If yes, you will receive an email from ACP asking you to submit a Letter of Support.)
No
Not applicable (Please state reason)
If not applicable, please state reason (i.e. Not required in my practice)
*
9.
Are you able to attend the Virtual Training Webinar on November 20, 2019 from 6:00 pm-8:00 pm EST?
(Required.)
Yes
No
10.
Indicate your agreement with the following statements:
Rating
Many of my patients are uninsured or underinsured
-- Select an option --
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I practice in a medically underserved community
-- Select an option --
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
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