Telehealth Technical Assistance Sign-up Sheet

Please complete the following information to register for the direct technical assistance opportunity offered by Telligen, in partnership with the University of Colorado Practice Innovation Program. Space is limited, completing this form enters you into the list for consideration. If you are not selected to participate in this opportunity, you will still receive the support materials and resources provided as part of this program. In addition, Telligen will continue to provide similar offerings in the future. This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. 12SOW-QIN-QIN-04/27/20-3674

Main Point of Contact Information

Name*

Title*

Email*

Phone Number*

Physician Champion Information

Name*

Credentials*

Email*

Practice TIN*

Practice NPI*

Address*

State*

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City*

Zip Code*

Practice Information

Location*

Unsure of location type? Use the lookup tool links below to find out. Medically Underserved Area (MUA) Lookup link: https://data.hrsa.gov/tools/shortage-area/mua-find Medically Underserved Population (MUP) Lookup link: https://data.hrsa.gov/tools/shortage-area/mua-find Health Professional Shortage Area (HPSA) Lookup link: https://data.hrsa.gov/tools/shortage-area/by-address Rural Lookup link: https://data.hrsa.gov/tools/rural-health

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Number of Clinicians*

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Is your practice accredited as a Patient-Centered Medical Home?*

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Type of organization*

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Practice Specialty*

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Percentage of Medicare Population?*

Estimated Payer Mix:

Please provide a percentage of your payer mix below. The total should equal 100%.

Medicare*

Medicaid*

No insurance*

Commercial*

Other*

Registered for Telligen QI Connect?*

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Availability

By signing up for this project, you are committing to attend six training sessions, 1 per week for 6 consecutive weeks. Please indicate below the days and times these sessions would work best with your schedule: Select all that apply:

Day(s)*

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Time(s)*

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