ECHO National Nursing Home COVID Action Network (NNHCAN)

Thank you for your interest in becoming a sub-contractor for this important project. Please complete all fields in the form to the right. Please number and name attachments with your institution's legal name followed by title of document (example: "1. UNM Substitute W9") in the following order: 1. Attachment 3B: Please complete this document in its entirety, and confirm that your institution has an active SAM.gov registration on page 1. You must be registered in SAM.gov in order to receive a federal subcontract. 2. Delivery-based Payment Schedule 3. Substitute W9 4. F&A Rate Agreement 5. Scope of Work Thank you for partnering with us to bring life-saving knowledge and care to thousands of nursing homes across the country!

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Enter the name of the person responsible for budget and contract submission.

Enter primary contact for NHCAN program management.

Is your institution a Medicare/Medicaid provider?*
Have you completed ECHO Immersion training?*
Have you completed Nursing Home CAN orientation?*
Has anyone on this hub team launched a program before?*

A cohort consists of groups of 30-35 nursing homes participating in the ECHO program.

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Will you partner with other organizations to launch cohorts?*

Select all documents you will be uploading from the list below.

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Please format the document title with your legal name (example, Amistad 2020 W9).

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