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* 1. Provider Name:

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* 2. Are you planning to apply for certification as a Care Management Agency (CMA)?

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* 3. Are you planning to apply for certification as an Advanced Medical Home Plus (AMH+)

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* 4. If yes. Please indicate the population(s) for which they are applying to be certified.

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* 5. What region(s) are you applying to be a CMA?

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* 6. What counties are you applying to be a CMA?

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* 7. Are you planning to work with a Clinically Integrated Network?

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* 8. Do you anticipate needing a platform or system to meet the Health Information Technology requirements?

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* 9. Provider Contact for CMA or AMH+:

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