Chronic Care Model Redesign Application Form
Apply to participate in the chronic care model redesign initiative. Please complete all required fields to ensure your application is considered.
Applicant Full Name
*
First Name
Last Name
Applicant Email Address
*
example@example.com
Organization or Practice Name
*
Role/Position in Organization
*
Briefly describe your current approach to chronic care management.
*
What are your primary goals or motivations for participating in the redesign initiative?
*
List key team members who will be involved in the redesign (names and roles).
*
How would you assess your organization's readiness for change?
*
Very ready
Somewhat ready
Not ready
Other (please specify)
I confirm that the information provided is accurate to the best of my knowledge.
*
I agree
Submit Application
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