Practice Site Approval Form
TCWD Residency Incentive Recipients must obtain APPROVAL for potential employment (service commitment) to remain in good standing with the program. Please note that just because a site was approved previously does not guarantee approval now or in the future.
Name
*
First Name
Last Name
Email
*
example@example.com
Specialty
*
Family Medicine
Internal Medicine
Med/Peds
OBGYN
Pediatrics
Psychiatry
Practice Site Name
*
Anticipated Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practice Site Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Site Contact Email
*
example@example.com
Are you committed to employment with this practice site:
*
YES
NO
Please provide the payor mix percentages for this practice site for the last 12 months- you will need to directly reach out to the PRACTICE SITE to get this information (TCWD looks at each individual practice site information).
*
Rows
% of patients for last 12 MONTHS:
TennCare/Medicaid
Uninsured
Medicare
Commercial Insurance
By signing below, you attest that the above information is true and correct to the best of your knowledge. Additionally, you are confirming you received the payor mix percentages directly from the practice site to give TCWD the most accurate information.
*
Submit
Should be Empty: