Practice Site Approval Form
TCWD Psych NP Incentive Recipients must obtain APPROVAL for potential post-graduate employment (the 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
Practice Site Name:
*
Practice Site Website:
*
Practice Site Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Site County:
*
Practice Site Contact Email
*
Site Administrator/Manager that can confirm information.
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).
*
% of patients for last 12 MONTHS:
TennCare/Medicare
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: