Volunteer for MPCC Implementation Groups

Please select the areas in which you (or others) would like to participate, and provide your (or their) contact information below each selection.

I (or others) in my organization would like to participate in one or more Implementation Groups for the MPCC Top Priority Objectives for 2010:

PRACTICE TRANSFORMATION - Priority Objective:

Promoting Health Information Technology (HIT)

Name of Volunteer, Phone, E-mail:

PRACTICE TRANSFORMATION - Priority Objective:

PCMH Spread

Name of Volunteer, Phone, E-mail:

PRACTICE TRANSFORMATION - Priority Objective:

PCMH Change Package

Name of Volunteer, Phone, E-mail:

ENGAGING CONSUMERS:

Self-Management Support

Name of Volunteer, Phone, E-mail:

ENGAGING CONSUMERS:

Community Resources

Name of Volunteer, Phone, E-mail:

REBUILDING THE PRIMARY CARE WORKFORCE:

Workforce State Plan

Name of Volunteer, Phone, E-mail:

Please provide your information for our records:

Name of Person Completing Form: *

Organization: *

Date: *