Accountable Care Organization Clinic Onboarding Checklist

Accountable Care Organization Clinic Onboarding Checklist
Complete this checklist to onboard a clinic into the ACO program and confirm operational readiness. Provide only non-sensitive practice and workflow information.
Clinic and Contact Details
Legal Clinic Name
Preferred Clinic Name
Clinic Type / Specialty
Primary Contact Name
First NameMiddle NameLast Name
Job Title
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Street Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State / Province
Postal Code
Time Zone
ACO Program and Practice Profile
ACO Program Name
Onboarding Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected Go-Live Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of Providers
Approximate Patient Volume
ACO Enrollment Status
Other
Onboarding Readiness Items
Other
Operational Readiness Checklist
Operational readiness tasks completed
Notes or blockers
Should be Empty: