Contact Information

Please provide the following contact information for your physician champion, program coordinator, and practice. OAFP will reach out to you with next steps once your information is processed.

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* 1. Physician Champion First Name:

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* 2. Physician Champion Last Name:

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* 3. Physician Champion Designation (MD, DO, etc.):

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* 4. Physician Champion Email address (all program communications will be sent to this person):

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* 5. If there is another team member/program coordinator helping to facilitate the project, please include their information here. They will also receive program communications.

Program Coordinator First Name:

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* 6. Program Coordinator Last Name:

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* 7. Program Coordinator Designation:

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* 8. Program Coordinator Email:

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* 9. Practice Name:

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* 10. Practice Address:

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* 11. Practice City:

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* 12. Practice State:

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* 13. Practice Zip Code:

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* 14. Practice Phone Number:

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* 15. Practice County:

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* 16. Names of additional practice team members participating, if known:

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* 17. AAFP Number:

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* 18. ABFM ID:

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