TCWD Practice Site Incentive Application
Application is open to FQHCs, free/charitable clinics, critical access hospitals, rural health clinics and other underserved practice sites.
Practice Site Name (legal name of organization)
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Practice Site Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Site County:
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Site Contact Name
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First Name
Last Name
Site Contact Email
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example@example.com
Site Phone Number
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Website Link
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Site Designation
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Please Select
FQHC
Free/Charitable Clinic
Critical Access Hospital
Rural Health Clinic
Urban Underserved Clinic
Other
Years your organization has been in existence:
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Mission of your organization:
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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?
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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:
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Recruitment
Retention
Other
Discipline(s) of Clinician(s) you plan to recruit/retain:
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Family Medicine
Internal Medicine
OBGYN
Pediatrics
Psychiatrist
Psychiatric NP
Dentist
Work Schedule of Clinician(s) you plan to recruit/retain
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Full-time (32+ hours per week)
Part-time
Please describe in specific detail how you will use the funds:
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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:
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List of current staff positions: administrative, medical, etc.
Please indicate the site percentages below:
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% of patients seen at this site in the last 12 month:
% TennCare Patients
% Uninsured Patients
% Medicare Pateints
% Commerical Insurance Patients
How did you hear about this program?
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This Practice Site received the award previously
Other Practice Site provided information
Social Media: Facebook, Twitter, LinkedIn, Instagram
Search Engine
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:
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Submit
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