My Practice
Pre-Register/Apply to Participate
Name of Your Practice*:
Key participating clinician*:
Address 1*:
Address 2:
City*:
State*:
Zip*:
Phone*:
Fax:
Email Address*:
Years in Practice:
Number of Patients:
Type of Practice:
If other practice, please specify
family practice
internal medicine
geriatrics
other
Other (please specify):
Number of Clinical Staff in FT Equivalents*:
Number of Other Staff in FT Equivalents:
Average Age of Most Patients:
What are the practice's plans as a medical home?
It is currently certified
It will be certified in the next year
No plans at this time
Does not apply
* Required fields.
