Physician First Name * Physician Last Name * Physician E-mail * Physician NPI * Click Here to use the NPI Lookup from HHS and cut and paste results into the form Facility State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Facility City * - Select -value1value2value3value4 Facility - None -value1value2value3value4 Facility not listed in dropdown AMDA Member ID * Years Practicing in PALTC * Are you participating in an ACO? * yes no ACO / Accountable Care Organization Are you participating in BPCI? * yes no BPCI / Bundled Payments for Care Improvement Do you have advanced practice nurses care for your patients routinely? * yes no In this facility, I serve as: * Medical Director Attending Physician Both Medical Director & Attending Physician Submit
