CHIPRA Information Form

Posted on: February 3, 2011

Back to CHIPRA: How to Get Involved

CHIPRA Quality Demonstration Project

If you are interested in participating in the CHIRPA Quality Demonstration Grant, please fill out this information form:

Your Name (required)
Your Specialty (required)
Specialty - Specify if Other
Practice/Clinic Name (required)
Number of MDs at your site (required)
Do you participate in Medicaid? (required)

 Yes No

If you participate in Medicaid managed care, which program do you use?

 Family Health Network Harmony Health Plan Meridian NA

Street Address (required)
City (required)
State (required)
Zip Code (required)
Phone Number (required)
Email Address (required)
Fax Number
Please indicate below all the CHIPRA project areas you are interested in:

Other (specify):

Please indicate below which CHIPRA measure areas are of most interest to you:

This is the end of the CHIPRA Information Form. Please review your responses and please ensure that all required fields are complete. When you are ready to submit the form, please select the button below.