Midwest Direct Primary Care Alliance Application
Thanks for your interest in joining in the Midwest Direct Primary Care Alliance! We're a group of clinics (http://www.midwestdpcalliance.org/who) with an epicenter in Kansas City working together to bring the best care possible to our patients. This application is the first step in joining our ranks. Once we receive your application and it's positively screened by the Membership Committee, we invite you to our Quarterly Meeting. Following your attendance at our meeting, the Membership Committee approves or denies the membership.

Before you get started, here is some information from our Agreement, which each new member signs upon joining the Midwest Direct Primary Care Alliance:

WHAT WE DO
The Midwest Direct Primary Care Alliance (MDA) aims to:
- Promote collegial relationships between Direct Primary Care (DPC) practices in the Kansas City area and surrounding communities.
- Raise awareness of DPC in the community.
- Promote fair and transparent pricing for ancillary services, such as imaging, labs, specialist consults, specialty procedures, etc, in the best interest of our patients.

WHO WE ARE
For membership, one must:
- be a physician, nurse practitioner, or physician’s assistant practicing in a DPC clinic
- attend meetings and participate in the organization in good faith; efforts will be made to provide options for participating in meetings via live stream for those who cannot physically attend.
- engage in collegial, respectful relationships between DPC providers and clinics
- provide care with a commitment to transparency, to accessibility, and to practicing primary care to the fullest extent of each one's scope and license by using current, evidence-based practices.
- be approved for membership by the the Membership Committee, who will use not only the DPC definition and above criteria in their decision, but also the nature of products, services, treatment, treatment claims and pricing rendered by potential member clinics in their decision-making.

DEFINITIONS
Primary Care:
- Primary care providers are the first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Or, more succinctly, “If you’re the first one they call, you’re practicing primary care.”
Primary care is prevention, acute care, and chronic disease management.

Direct Care Practice:
- From Eskew, J Am Board Fam Med November-December 2015 vol. 28 no. 6793-801: "A DPC practice must be a primary care practice that (1) charges a periodic fee for services, (2) does not bill any third parties on a fee-for-service basis, and (3) any per-visit charges are less than the monthly equivalent of the periodic fee."

Last Name *
Your answer
First Name *
Your answer
Preferred Name (if different than legal name)
Your answer
Gender *
Degree (i.e. MD, DO, APRN, etc.) *
Your answer
Practice/Clinic Name *
Your answer
Preferred Email Address for Correspondence *
Your answer
Clinic Phone Number *
Your answer
Clinic Address *
Your answer
Clinic Website *
Your answer
Twitter Handle *
Your answer
Personal Cell Phone (for internal use; will not be made public) *
Your answer
Medical School/PA School/NP School *
Your answer
Year of Graduation from Medical School/PA School/NP School *
Your answer
Residency/Internship Site(s), if Applicable
Your answer
Year of Graduation from Residency/Internship, if Applicable
Your answer
Please give a brief background/history of your career and/or path towards DPC. *
Your answer
Would you be willing to host medical students at your practice site? *
Would you be willing to host NP students at your practice site? *
Would you be willing to host PA students at your practice site? *
Would you be willing to host residents at your practice site? *
If you are unwilling to host students and residents, what are your biggest hurdles or reasons you're not eager to host them? *
Your answer
What are you hoping to gain from joining the Midwest Direct Primary Care Alliance? *
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