Application and Agreement


Please submit one application for each Tax ID number.


If you are interested in participating in our Practice Transformation Network (PTN):

1. Complete the Application Form below.

2. Check the box to agree to the terms and conditions of the agreement.

3. Submit the form

Our PTN is offered through the Transforming Clinical Practices Initiative (TCPI)

1. APPLICATION

contact source

Do you currently participate in the following programs?

Other Program Participation  Hold the Control key to select more than one

Check this box if you would like to join an Alternative Payment Model or Accountable Care Organization in 2019 or 2020.  

Organization Name*

Organization Street Address*

Organization Street Address 2

Organization City*

Organization State*

Organization Zip*

Company Website*

Number of Critical Access Hospitals* (Please enter numerical values only)

Number of PPS Hospitals   PPS Hospital Definition * (Please enter numerical values only)

Number of Federally Qualified Health Centers* (Please enter numerical values only)

Number of Fee for Service Practices* (Please enter numerical values only)

Number of Rural Health Clinics* (Please enter numerical values only)

Other Facility Types (List all)

Number of Primary Care Providers* (Please enter numerical values only)

Number of Specialty Care Providers* (Please enter numerical values only)

Number of Patients Served (approx - thousands)* (Please enter numerical values only)

Electronic Health Record used (List all)*

Certified as a Patient Centered Medical Home?  

Independent Physician Association?  

Independent Physician Association Name

How Did You Hear About Us?*

Referred by*

2. PARTICIPANT AGREEMENT

National Rural Accountable Care Consortium Practice Transformation Network Participation Agreement

The Consortium is a non-profit organization that supports healthcare transformation.  The primary aim of the Consortium is practice transformation to improve care, reduce unnecessary healthcare costs, and improve patient satisfaction, all while also improving the financial performance and sustainability of health systems.

The Participant owns or operates a clinician practice that bills Medicare for and desires to participate in the TCPI through the Consortium in order to develop the tools, skills and knowledge necessary to successfully participate in shared savings programs and other alternative payment models.

As a participant in the Consortium’s PTN, I agree that I and my practice will:

  • Work collectively and collaboratively with other participants of the Consortium's TCPI program to develop the tools, skills and knowledge needed for the Participant and other participants to successfully participate in shared savings programs and other alternative payment models.

The term of this Agreement shall start on the date this Agreement is signed by the Participant.

PARTICIPANT OBLIGATIONS

I and my practice agree that we will:

  • Work with the Consortium to develop the tools, skills and knowledge the Participant and its clinicians will need to successfully participate in shared savings programs and other alternative payment models.
  • Participate in the processes, programs and initiatives developed by the Consortium as a part of its TCPI program, if possible.
  • Send our practice manager(s) and care coordinator(s) to four one-day Consortium quarterly workshops per year so that the Participant can develop the knowledge and skills necessary to redesign workflows to optimize ambulatory quality performance.
  • Receive reimbursement for related travel expenses in accordance with the Consortium travel policy, as described above. (LINK TO TRAVEL POLICY)
  • Send its executive and physician leadership to one one-day Consortium Regional Meeting per year so that the Participant can develop the knowledge and alignment necessary to be successful under value-based payment models. Related travel expenses will be reimbursed in accordance with the CONSORTIUM travel policy, as described above.
  • Participate in quarterly Clinical Initiative webinars provided by the Consortium that support the TCPI national aims.  
  • Participate in a readiness assessment and will provide the quality and cost data requested by the Consortium.  The Participant and its clinicians will participate in the Merit-Based Incentive Program, where possible. If the Participant is a Rural Health Clinic or Federally Qualified Health Center, the Participant and its clinicians shall report requested quality data to the Consortium using Lightbeam Health Solutions (or other information technology platform designated by Consortium).
  • Cooperate and work with Consortium staff to integrate and interface the Participant's information technology system (including its electronic health and medical record system(s)) with Consortium's information technology system and data warehouse (Lightbeam Health Solutions).
  • Disclose to Consortium whether the Participant or any of its clinicians are participating in another TCPI practice transformation network, or in a Medicare, Medicaid or CHIP value based payment program or demonstration project (collectively, a CMS Project).
  • Provide to Consortium the National Provider Identifier (NPI) and Provider Enrollment, Chain and Ownership System (PECOS) information for Participant and each of its clinicians.  Participant will notify Consortium of any changes in the clinicians in the Participant's practice (new hires, resignations or terminations) within 15 days of the change.

This Agreement (see link to full agreement below) is subject to the terms and conditions of the TCPI Cooperative Agreement, Programmatic Terms and Conditions (the Cooperative Agreement).  The Participant agrees to comply with the applicable terms of the Cooperative Agreement, and to provide to Consortium such item or service necessary for Consortium to comply with the terms of the Cooperative Agreement.  The Participant may be ineligible to participate in the TCPI if it is currently participating in a CMS Project, and cannot participate in more than one TCPI practice transformation network.

Consortium and Participant agree to comply with the terms and requirements of Exhibit A, "TCPI PROGRAM REQUIREMENTS," which by this reference is incorporated herein.  The terms and requirements of this Article IV and Exhibit A shall survive the expiration or termination of this Agreement.

By checking this box, I agree to become a participant in The Consortium's Practice Transformation Network and will comply with all terms and conditions of the participation agreement.

 

Agree to participate - Date?*

First Name*

Last Name*

Title*

Email*

Email 2

Phone*

Extension


3. SUBMIT

Application is not complete until you press submit button.

 

 


Organized Health Care Arrangement (OHCA) Declaration


Please download and save for your records:

Full Contract Terms & Conditions

Travel and Expense Policy: These are the policies to follow for pre-authorized project travel reimbursement.


Thank you for your time.