PTN Enrollment

* 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 

* 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 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 (