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We're Ready to Enroll in the Mid-Atlantic CMS QIN-QIO (Region 2)
Congratulations on your decision to participate in this important healthcare quality improvement initiative. Submit this form to secure your spot. Once we receive your submission, we will schedule a brief "Getting Started" session.
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Your First Name
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Your answer
Your Last Name
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Your answer
Your Title
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Your answer
Your Email
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Your answer
Your Facility Type
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Nursing Home
Hospital
Outpatient Clinical Provider
Your Facility Name
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Your answer
Your Facility Street Address
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Your Facility City
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Your Facility State
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Your Facility Zip Code
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CCN Number (if available)
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What is the best telephone number for us to reach you?
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Please indicate the name, title and email address of any others whom you would like to include in future communications.
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Do you have any additional comments for the team?
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