PTN Enrollment

Practice and/or Health System Name
Please list the name that is registered to your clinic's TIN if possible; if you have any questions, please contact TCPI@doh.wa.gov. 

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* 1. Practice and/or Health System Name
Please list the name that is registered to your clinic's TIN if possible; if you have any questions, please contact TCPI@doh.wa.gov. 

Street Address (including suite number)

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* 3. Street Address (including suite number)

City

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* 4. City

Zipcode+4

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* 5. Zipcode+4

County

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* 6. County

Who is the main point of contact for your clinic?

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

Point of contact title (Clinic Administrator, etc)

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

Point of contact phone

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* 9. Point of contact phone

Point of contact email address

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* 10. Point of contact email address

Name of person submitting this form

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* 11. Name of person submitting this form

Phone number or email address of submitter

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* 12. Phone number or email address of submitter

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, 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 (melissa.thoemke@doh.wa.gov).

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