Practice Site Incentive Application

TCWD Practice Site Incentive Application

Application is open to FQHCs, free/charitable clinics, critical access hospitals, rural health clinics and other underserved practice sites. Acceptable positions for use of funds are primary care physicians, psychiatrists, psych nurse practitioners, and dentists. Once an application is submitted, please allow 3-4 weeks for a response.
Practice Site Name (legal name of organization)
Practice Site Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Site County:
Site Contact Name

First NameLast Name
Site Contact Email
example@example.com
Site Phone Number
Website Link
Site Designation
Years your organization has been in existence:
Mission of your organization:
Funds Request: Sites are allowed up to $50,000 to recruit or retain primary care physicians, psychiatrist, psychiatric NP, or dentists. How much are you requesting for your recruitment/retention?
Funds can be used for: relocation expenses, insurance, sign-on bonuses, retention bonuses, loan repayment, CME, and in some cases special equipment. Funds cannot be used for salaries, recruitment agency fees, or general equipment/tech fees.
Planned use for incentive funds:
Discipline(s) of Clinician(s) you plan to recruit/retain:
Work Schedule of Clinician(s) you plan to recruit/retain
Please describe in specific detail how you will use the funds:
Please note funds can only be used towards the benefit of clinicians that are providing direct patient care.
Please describe the current staffing of your practice site:
List of current staff positions: administrative, medical, etc.

Please indicate the site percentages below:

Rows	% of patients seen at this site in the last 12 months:
% TennCare Patients
% Uninsured Patients
% Medicare Patients
% Commerical Insurance Patients

How did you hear about this program?

Other
Additional Comments:
Currently in negotiation with clinician? Timeline of hiring? Schedules of clinicians, etc.
I attest that the information provided in this application is true to the best of my knowledge:
Should be Empty:

TCWD Practice Site Incentive Application