1/29/10

Application – System Orientation

Instructions: Place your cursor in the grey boxes to enter text.

  1. Applicant Information

Applicant

Organization:

Address:

City, State, Zip:

Mailing Address (if different):

What type of organization is the applicant?

CEO Information

Salutation:

Name:

Title:

Address:

Phone:

Fax:

Email:

Contact Information

Salutation:

Name:

Title:

Address:

Phone:

Fax:

Email:

  1. Service Area Information

List the primary (and secondary, if any) contiguous geographic area(s) to be served by the network and other possible geographical partners. Use only the space provided.

Use the table below to describe the current organizations/programs, including the applicant, that provide healthcare services to the low income uninsured people in this area.

Organization Name / CEO Name / Primary Services Provided

Have there been any recent efforts to objectively assess healthcare resources and needs within the service area? Yes No

If yes:Conducted by:

Date completed:

III.Partnerships

Document each of the following organizations’ participation in the network.

Required Members

Organization Type / Organization Name(s) / Member Name(s) / Member Title(s)
Community Health Center/ Federally Qualified Health Center
Free Medical Clinic
Local Health Department
Hospital
Local Behavioral Health Agency
Medication Provider
Private Providers
Rural Health Clinic

If there are any Required Members in the community to be served by the network that are not listed above, explain the absence.

Other Members (other than the Required Members listed above)

Organization Type / Organization Name(s) / Member Name(s) / Member Title(s)
  1. Leadership

Who in your community will be the administrative leader and the clinical leader for your local network development? (See ‘Frequently Asked Questions’ at for leader characteristics.)

Administrative Leader:

Clinical Leader:

Why do you think they could lead network development?

  1. Ability to Focus

Describe the need for the organizations/programs listed above to improve coordination among each other for the purpose of increasing access to care and improving efficiency and effectiveness of patient healthcare services. Use only the space provided.

  1. Trust

Describe one recent effort related to organized and purposeful collaboration for the improvement of patient care among the Required Members listed in section III. Use only the space provided.

How can AccessHealth SC best help your community improve its healthcare delivery system to better serve the uninsured?

  1. Electronic Signature

I am submitting this application to AccessHealth SC for technical assistance related to development of a community-based healthcare network.

Signature: Date:

Title:

Checking this box indicates an electronic signature of the applicant’s CEOand affirms all the information listed above.

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