Autism Quality Improvement - Practice Registration Form

Information about your practice

Thank you for your interest in the Autism Quality Improvement Program. Each participating practice must complete this Practice Registration Form. This form needs to to be completed only once for your practice.

If you have any questions, please contact Sharissa Epps at sepps@chadis.com or 888-424-2347 Ext. 12

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* 1. Please enter the following information about the organization/practice:

Organization/Practice Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Phone Number: *

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* 2. Fax number

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* 3. Name of person completing this form

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* 4. What is your role or job title in the practice?

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* 5. What is your email address?

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* 6. Is there another person, other than yourself, who will serve as the main administrative or front desk contact, for the purposes of the Autism Quality Improvement Program?

Yes, there is someone other than myself who will serve as the main contact person.

No, I am the main administrative contact person.