Episode-Based Payment Program Application Form

Episode-Based Payment Program Application Form
Apply to participate in an episode-based payment program by providing your organization and program details below.
Organization Name*
Contact Person's Full Name*
First NameLast Name
Contact Email Address*
example@example.com
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Organization Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Organization*
Orthopedic SurgeryCardiac CareMaternity CareOncologyOther
Briefly describe your organization's experience with episode-based payment models or bundled payments.*
Expected Start Date for Program Participation*
MonthDayYear
Date
Upload supporting documents (e.g., program proposal, evidence of capacity, relevant certifications)
Cancelof
Fixed Episode PaymentShared SavingsPay-for-PerformanceOther
Estimated Number of Episodes per Year*
Should be Empty: