Project ECHO: MAT in the Primary Care Setting (SUPPORT for ME) Application

Applicant Information

Instructions:

For Practice Care Teams interested in participating in the upcoming Project ECHO focused on building the competency and capacity for Primary Care prescribers and practice teams in Maine to offer Medications for Addiction Treatment (MAT) services for patients with Opioid Use Disorder. Please complete the following application and statement of collaboration. This ECHO is open to practices that have at least one X-waivered prescriber, together with their full care team.

Question Title

* 1. Practice Information

Practice Name

Practice Location

Health Care System (if applicable)

Question Title

* 2. Primary Contact

Name

Title

Credentials

Email Address

Phone Number

Project ECHO: MAT in the Primary Care Setting (SUPPORT for ME) Application

Applicant Information

Question Title

* 1. Practice Information

Question Title

* 2. Primary Contact

Question Title

* 3. Please list all additional team members that will be joining the ECHO below and include: name, title, credentials and e-mail address.