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Community Partnership Participation

Community Partnership Participation Agreement

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The most effective way to impact health care is to align efforts with those who have common goals. Under contract with the Centers for Medicare & Medicaid Services, Mountain Pacific works with local, state and national partners to achieve quality improvement—and you will benefit and learn from these efforts! We look forward to partnering with you to improve outcomes and thank you for your commitment to quality.
Please provide the requested information below to participate in our programs.

Fields/questions with an asterisk * are required.

Primary Contact Information:

Address * Required

Secondary Contact Information:

Questions

Where can you use our support? (Check all that apply.)
Mountain Pacific has permission to disclose our relationship with your organization in relation to quality improvement projects and to use and/or publish information regarding the organization’s quality improvement efforts, including interventions, literature, documents, images, graphs or other materials, for the purpose of furthering the advancement of health care quality. This is to include print, electronic, visual, verbal, Internet and/or various media through November 7, 2024. This release and consent are made without compensation and no compensation is required or anticipated. * Required
This participation agreement between your organization and Mountain-Pacific Quality Health is in effect through November 2024.

If you prefer to print and sign this participation agreement, below is a blank copy of this form that can be printed. Once completed, you can email a signed copy to your account manager or ealm@mpqhf.org. The form can also be faxed to (406) 513-1920 or mailed to Ericka Alm at P.O. Box 5119 Helena, MT 59604.

Community Partnership Participation Agreement PDF
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