PTN Enrollment

* 1. Practice and/or Health System Name

* 3. Street Address (including suite number)

* 4. City

* 5. Zipcode+4

* 6. County

* 7. Who is the main point of contact for your clinic?

* 8. Point of contact title (Clinic Administrator, etc)

* 9. Point of contact phone

* 10. Point of contact email address

* 11. Name of person submitting this form

* 12. Phone number or email address

A practice facilitator assigned to your clinic will be in touch with you via email shortly to set up an initial meeting to introduce the initiative. The initiative includes a Practice Assessment Tool and a payment incentive for your clinic upon completion, which will also be discussed during this first meeting. If you have any questions before that time, please reach out to Melissa Thoemke, Program Manager for P-TCPI (