Rural Healthcare Provider Transition Project Application

Lead Organization & Primary Contact Information




Please include suite on a second line




Chief Executive Officer Information




You may provide extension information in this field.



Administrative Assistant Information





You may include extensions in this field.




Contact Person
Communication about this application will be directed to this individual.






You may provide extension information in this field.




Ownership




Application Information
Program Participation
Please check all that you participate in.
Please rank the order of the following quality focus areas to indicate you need.  Please select a number only once.

1=biggest need for your organization /  4=least amount of need for your organization





Please indicate your status for the following non-Medicare alternative payments or care delivery models. 



Eligibility Requirements

I have read and confirm that my organization meets all eligibility requirements to participate in the Rural Healthcare Provider Transition Project.

Will the applicant's governing body and/or principal sign a letter of commitment to work closely with HRSA's technical assistance provider(s) to achieve the objectives of the Rural Healthcare Provider Transition Project?

Participation Expectations
I have read and I'm in agreement with the participation expectations . I understand that the participation requirements are the basic necessities that my health care organization must be willing and able to meet to fulfill the RHPTP purpose and goals.
Confirmation

The CEO, Contact Person and Administrative Assistant will receive an email confirmation that the online application was successfully submitted. If you have any questions, please contact Rhonda Barcus at (904) 321-7607 or rhptp@ruralcenter.org.