To indicate your desire for consideration in a 2018 Accountable Care Organization (ACO), please submit the non-binding Letter of Intent below by April 30, 2017.


1. Complete the Application Form below.

2. Check the box to agree to the terms and conditions of the Letter of Intent.

1. Apply

First Name*

Last Name*

Title*

Phone*

Extension

Email*

Email 2

Assistant First Name

Assistant Last Name

Assistant Email

Assistant Phone

Assistant Phone Extension/Other Phone

Organization Name*

Organization Street Address*

Organization Street Address 2

Organization City*

Organization State*

Organization Zip*

Organization Website

Number of Rural Health Clinics*

Number of Federally Qualified Health Centers*

Number of Fee for Service Solo Practices*

Number of Fee for Service Group Practices*

Number of Skilled Nursing Facilities*

Number of Hospitals*

Number of Critical Access Hospitals*

Other Facility Types (List all)

Number of Primary Care Providers*

Number of Nurse Practitioners/Physican Assistants*

Number of Specialists Practicing in Ambulatory*

Number of Licensed Acute Beds*

Number of Population Served (approx – thousands)*

Percent of Population Receiving Medicaid Benefits*

Electronic Health Record Used (List all)*

Certified as Patient Centered Medical Home?

Independent Physician Association

Independent Physician Association Name

Stage Meaningful Use (If applicable)

How Did You Hear About Us?*

Referred by

2. Letter of Intent

Caravan Health Letter of Intent Agreement

This Non-Binding Letter of Interest (“Letter”) is intended to memorialize your organization’s interest in learning more about the Accountable Care Organization (“ACO”) program offered by Caravan Health (“Caravan”), and your organization’s desire to start the application process for participating in the Medicare Shared Savings Program sponsored by the Center for Medicare & Medicaid Services.

For clarity, this Letter is not intended to be and will not create any legally binding obligations on the parties. Should the parties desire to enter into a legally binding relationship with enforceable rights and obligations, that relationship will be memorialized in a separate written and executed document (“Definitive Agreement”). The terms and conditions of any such Definitive Agreement will be negotiated by the parties at that time.

By submitting this Letter, you are authorizing Caravan to contact you at the email address and phone number provided.

  Agree to participate?*

3. Submit