Thank you for your interest in serving on the Primary Care Information Project's Physician Advisory Council. Please complete this brief application by Friday, March 9, 2018.  

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* 1. First name:

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* 2. Last name:

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* 3. Email:

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* 4. Practice name:

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* 5. Role and responsibility at the practice:

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* 6. Practice type:

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* 7. Provider type:

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* 8. Please select the type of care you provide.
(check all that apply)

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* 9. Please indicate the payer percentages associated with each category (should total 100%):

 
Medicaid
Medicare
Dual Eligible
Private/Commercial
Uninsured/Self-Pay

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* 10. Is your practice participating in a value-based payment payer contract (i.e. two sided risk)?

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* 11. Please select your DSRIP PPS affiliation.
(check all that apply)

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* 12. Please list and describe any key leadership roles within the past five years.

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* 13. Please list any experience serving on a council or board.

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* 14. Please list any professional affiliations.

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* 15. Which of the following strategies do you currently employ to actively address health disparities?
(check all that apply)

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* 16. Which of the following cultural competence strategies would you like to further develop or employ in your practice?
(check all that apply)

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* 17. Why do you want to join PCIP’s Physician Advisory Council?

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* 18. How do you think you could most successfully represent your physician peers on this advisory council?

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* 19. PCIP Advisory Council meetings are scheduled quarterly, and last approximately 2 hours. Can you commit to attending at least 3 of the 4 in-person meetings per year?

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* 20. In addition to in-person meetings, we expect to ask for the Council's input through email discussions, surveys, and phone conversations as needed. Are you willing to participate in these ongoing discussions?

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