(in case we have questions)
The preferred name that the organization uses (or will use) to market itself to the general public.
This is the physical/street address that we will use to geolocate the center on our online PACE Finder. If you use a different address for mailing/billing, please list that as well.
This is generally a main administrative office phone number.
Please list any authorized email domains for your organization. This will be used to validate any NPA accounts created under your organizational membership (e.g. @mypace.org).
This is a number, typically in the format H1234, that is assigned by the Centers for Medicare & Medicaid Services (CMS) after submitting the Notice of Intent to Apply. Depending upon where you are in development, you may not yet have an H number.
Date of execution of three-way agreement with CMS, state administering agency and the PACE program. Depending upon where you are in your PACE development, you may have not yet executed your agreement. If so, leave blank.
This is your best estimate at this time. We know many factors influence the ultimate opening date. This is the date you project to start serving enrolled participants/receiving your capitated payments. It is always the 1st of the month.
If you will have parent or sponsoring organizations/entities for the legal entity that is planned to provide PACE services, please list them below. We will extend your Prospective PACE organization membership to them on a complimentary basis. Please list the organization name and its approved email domain for verification purposes (e.g. XQZ Health System, @xyzhealthsystem.org)
You may have other staff at your organization who are involved in the PACE development process and would benefit from NPA member benefits. You may have even started hiring staff dedicated to the PACE program itself. Our memberships are done on an organizational basis. Once your organization is approved as a member, all of the benefits of membership are available to anyone on your team. We encourage you to extend NPA member benefits to all staff.
This field is required
If you are creating a list, we'll need the same information that we asked for you above (full name, postnominal, job title, email, preferred direct phone number). Or, if it's easier for you, feel free to upload an existing staff roster. Word and excel files preferred, but we can also accept PDF files.
This information is optional, but helps us to better serve you and your organization's particular needs.
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