M-DHAN Community Partner Registration

Contact Information

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* 1. Application Date:

Date

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* 2. First Name:

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* 3. Last Name:

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* 4. Credentials:

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* 5. Title:

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* 6. Organization:

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* 7. Business Address:

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* 8. Business Address 2:

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* 9. City:

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* 10. State:

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* 11. Zip Code:

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* 12. Email:

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* 13. Business Phone Number:

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* 14. Cell Phone Number:

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* 15. Fax Number:

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* 16. How did you hear about the MD-HAN?

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* 17. Are you interested in participating in any of the following M-DHAN Work Groups?

Data/Technology - (The M-DHAN Data and Technology Work Group provides expert analysis and recommendations on technology solutions in support of a coordinated healthcare delivery system.)

Primary Care Safety-Net - (The M-DHAN Primary Care Safety Net Work Group examines access issues and collaborates towards finding solutions focused on improving primary care and the local safety-net)

Community Health Worker/Patient Navigator - (The M-DHAN Community Health Worker/Patient Navigator Work Group exchanges and disseminates best practices/lessons learned throughout the Network contributing to the enhancement of service delivery among CHWs and PNs.)

Innovation/Impact - (The MD-HAN Innovation Work Group Forges key community partnership with interested participants who are focused on research, innovation and impact. The M-DHAN Impact Work Group Ensures all collaborative efforts undertaken by the Network are measurable, sustainable and have a positive impact in the health and well-being of the community.)

None of the above