Fillable MTPCMH Program App 2015 (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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MTPCMH Program App 2015 (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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MONTANA PCMH PROGRAM PRELIMINARY APPLICATION
PRACTICE INFORMATION
Practice Name:
Address:
City/State/Zip:
If the practice site is part of a larger organization that is submitting applications for other practice sites as well, please
identify the name of the larger organization:
Is the practice a Federally Qualied Health Center (FQHC)?
Have you obtained PCMH recognition/accreditation from a national accrediting organization?
If yes, which agency?
If yes, what date was accreditation received?
Please attach any letters of recognition/accreditation from national organizations.
Are you actively seeking PCMH recognition/accreditation from a national accrediting organization?
If yes, which organization?
If yes, when do you anticipate receiving recognition?
Yes
No
Yes
No
Yes
No
CONTACT INFORMATION
Contact Name: Contact Title:
Contact Email: Phone:
Please submit the form via email to Amanda Eby at aeby@mt.gov. Email is the preferred submission method. You can
also submit it by postal mail to 840 Helena Ave., Helena, MT 59601.
Monica J. Lindeen
Commissioner of Securities & Insurance
Montana State Auditor
840 Helena Ave. • Helena, MT 59601
Phone: 406.444.2040 or 800.332.6148
Fax: 406.444.3497 • Web: www.csi.mt.gov
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MTPCMH Program App 2015 (Montana Office of the Commissioner of Securities and Insurance, Montana State Auditor)

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Completed 13 August 2020

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