Submit a New Site to Our Directory - Integrated Care News

1) Basic Organizational Info

Organization Name *

Organization Web Address

Eg. where patients could find more information

Contact Name *

Contact Email *

Street Address of the Main/Central Organization *

Street: eg. 103 Harlow Street

City *

State / Province *

Zip Code *

2) Services & Sites

Type of Services Your Organization Offers

Check all that apply

Other Types of Services

Number of total sites your organization has

Eg. number of locations patients can access ANY services within your organization

Number of total sites offering integrated care services

Eg. number of locations patients can access integrated care services within one organization

Type of integrated care or co-located services offered by your organization

	Type of Integrated Care	Availability
1		Offered at All Our Sites Offered at Some of Our Sites Not Offered
2		Offered at All Our Sites Offered at Some of Our Sites Not Offered
3		Offered at All Our Sites Offered at Some of Our Sites Not Offered
4		Offered at All Our Sites Offered at Some of Our Sites Not Offered
5		Offered at All Our Sites Offered at Some of Our Sites Not Offered
6		Offered at All Our Sites Offered at Some of Our Sites Not Offered
7		Offered at All Our Sites Offered at Some of Our Sites Not Offered
8		Offered at All Our Sites Offered at Some of Our Sites Not Offered
9		Offered at All Our Sites Offered at Some of Our Sites Not Offered
10		Offered at All Our Sites Offered at Some of Our Sites Not Offered
11		Offered at All Our Sites Offered at Some of Our Sites Not Offered
1		Offered at All Our Sites Offered at Some of Our Sites Not Offered

Any additional or other types of integrated care offered by your organization?

Access To Services: Do some or all patients have access to integrated care services?

3) Additional Info

Brief Organization Description

1-2 Sentences describing what services you offer patients

Estimate of the number of unique patients served annually by your organization

Eg. # unique patients seen for any services across all sites - NOT number of patient visits

Is your organization accepting new patients?

Is this organization a training site?

YesNo

Training Contact Name

Training Contact Email

Training Contact Phone

4) Locations

Primary Location

Add Additional Locations

	Location on Map	Notes
1

5) Review & Submit

Please give us feedback or make any notes with respect to this registration.

Note, this response will not be published.

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