Health First Colorado: APM 2 Provider Interest Form

Health First Colorado: APM 2 Provider Interest Form

Purpose

This form is intended for the Department to track interest in the APM 2 program. For practices who would like to see their practice-specific model and are ultimately interested in participating in the program, please fill out this form. A member from the Payment Reform team will follow up with each request.

Date of Submission*

Date you are submitting this request

Contact Name*

Please provide the name of the best person to contact regarding the APM 2 program.

Contact Email*

PCMP Status*

Are you currently a Primary Care Medical Provider (PCMP) in the Accountable Care Collaborative (ACC)?

Select or enter value

Medicaid Billing ID*

What is the Medicaid billing ID for your practice? (For multiple practices, please separate IDs with a semicolon).

Name of Practice(s)*

Please include the name of the practice(s) for which you are submitting this request.

Fill out if you would like us to include your RAE representative in your model presentation:

Please include the name and email address for your RAE representative

Send me a copy of my responses

Privacy Notice|Report Abuse