{"id":269250,"date":"2019-11-11T13:31:15","date_gmt":"2019-11-11T20:31:15","guid":{"rendered":"https:\/\/93fd47b736.nxcli.net\/QIO\/?page_id=269250"},"modified":"2024-10-09T13:44:32","modified_gmt":"2024-10-09T19:44:32","slug":"community-partnership-participation","status":"publish","type":"page","link":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/community-partnership-participation\/","title":{"rendered":"Community Partnership Participation"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_31' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Community Partnership Participation Agreement<\/h2>\n                            <p class='gform_description'>Please note: this form may time out when accessed on certain internet browsers. If you are concerned this page may time out before you are able to complete the form, or if you are unable to complete the form in one sitting, you can save your progress by clicking the \u201cSave and continue later.\u201d text at the bottom of the form.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_31'  action='\/QIO\/wp-json\/wp\/v2\/pages\/269250' data-formid='31' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_31' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_31_25\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_25\" >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\u2014and 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.<br\/> Please provide the requested information below to participate in our programs.<br\/><br\/>Fields\/questions with an asterisk * are required.<\/div><div id=\"field_31_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_13\" ><h3 class=\"gsection_title\">Primary Contact Information:<\/h3><\/div><div id=\"field_31_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_1\" ><label class='gfield_label gform-field-label' for='input_31_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_31_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_31_18\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_18\" ><label class='gfield_label gform-field-label' for='input_31_18'>Title\/Role<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_31_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_31_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_3\" ><label class='gfield_label gform-field-label' for='input_31_3'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_31_3' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_31_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_4\" ><label class='gfield_label gform-field-label' for='input_31_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_31_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_31_5\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_5\" ><label class='gfield_label gform-field-label' for='input_31_5'>Organization Name<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_31_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_31_6\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_6\" ><label class='gfield_label gform-field-label' for='input_31_6'>Organization Type<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_31_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_31_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_31_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_31_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_31_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_31_7_1' id='input_31_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_31_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_31_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_31_7_2' id='input_31_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_31_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_31_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_31_7_3' id='input_31_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_31_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_31_7_4' value=''      aria-required='true'    \/>\n                                        <label for='input_31_7_4' id='input_31_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_31_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_31_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_31_7_5' id='input_31_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_31_7_6_container' >\n                                        <select name='input_7.6' id='input_31_7_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_31_7_6' id='input_31_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/fieldset><div id=\"field_31_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_19\" ><h3 class=\"gsection_title\">Secondary Contact Information:<\/h3><\/div><div id=\"field_31_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_21\" ><label class='gfield_label gform-field-label' for='input_31_21'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_31_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_31_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_20\" ><label class='gfield_label gform-field-label' for='input_31_20'>Title\/Role<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_31_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_31_22\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_22\" ><label class='gfield_label gform-field-label' for='input_31_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_31_22' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_31_23\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_23\" ><label class='gfield_label gform-field-label' for='input_31_23'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_31_23' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_31_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_14\" ><h3 class=\"gsection_title\">Questions<\/h3><\/div><fieldset id=\"field_31_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Where can you use our support? (Check all that apply.)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_31_9'><div class='gchoice gchoice_31_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Opioid Use and Misuse'  id='choice_31_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_1' id='label_31_9_1' class='gform-field-label gform-field-label--type-inline'>Opioid Use and Misuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Care Coordination'  id='choice_31_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_2' id='label_31_9_2' class='gform-field-label gform-field-label--type-inline'>Care Coordination<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Health Equity'  id='choice_31_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_3' id='label_31_9_3' class='gform-field-label gform-field-label--type-inline'>Health Equity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Improve Nursing Home Quality'  id='choice_31_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_4' id='label_31_9_4' class='gform-field-label gform-field-label--type-inline'>Improve Nursing Home Quality<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Chronic Disease Management'  id='choice_31_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_5' id='label_31_9_5' class='gform-field-label gform-field-label--type-inline'>Chronic Disease Management<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Immunizations'  id='choice_31_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_6' id='label_31_9_6' class='gform-field-label gform-field-label--type-inline'>Immunizations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Emergency Preparedness'  id='choice_31_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_7' id='label_31_9_7' class='gform-field-label gform-field-label--type-inline'>Emergency Preparedness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_31_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Other (We will contact you!)'  id='choice_31_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_9_8' id='label_31_9_8' class='gform-field-label gform-field-label--type-inline'>Other (We will contact you!)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_31_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_17\" ><legend class='gfield_label gform-field-label' >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\u2019s 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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_31_17'>\n\t\t\t<div class='gchoice gchoice_31_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_31_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_31_17_0' id='label_31_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_31_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No (If you answer No, your organization is still eligible to participate.)'  id='choice_31_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_31_17_1' id='label_31_17_1' class='gform-field-label gform-field-label--type-inline'>No (If you answer No, your organization is still eligible to participate.)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_31_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_31_10\" ><em><strong>This participation agreement between your organization and Mountain-Pacific Quality Health is in effect through November 2024.<\/strong><\/em>\n\n<br>\n<p>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\nHelena, MT 59604.<\/p>\n<a href=\"https:\/\/www.mpqhf.org\/QIO\/wp-content\/uploads\/2022\/08\/Community-Participation-Agreement-August-2022-508.pdf\">Community Partnership Participation Agreement PDF<\/a>\n\n<\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_31' class='gform_button button' value='Submit Agreement'  onclick='if(window[\"gf_submitting_31\"]){return false;}  if( !jQuery(\"#gform_31\")[0].checkValidity || jQuery(\"#gform_31\")[0].checkValidity()){window[\"gf_submitting_31\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_31\"]){return false;} if( !jQuery(\"#gform_31\")[0].checkValidity || jQuery(\"#gform_31\")[0].checkValidity()){window[\"gf_submitting_31\"]=true;}  jQuery(\"#gform_31\").trigger(\"submit\",[true]); }' \/> <button type='button'  id='gform_save_31_footer_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_31\"]){return false;}  if( !jQuery(\"#gform_31\")[0].checkValidity || jQuery(\"#gform_31\")[0].checkValidity()){window[\"gf_submitting_31\"]=true;} jQuery(\"#gform_save_31\").val(1); jQuery(\"#gform_31\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_31\"]){return false;} if( !jQuery(\"#gform_31\")[0].checkValidity || jQuery(\"#gform_31\")[0].checkValidity()){window[\"gf_submitting_31\"]=true;} jQuery(\"#gform_save_31\").val(1); jQuery(\"#gform_31\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and continue later.<\/button>\n            <input type='hidden' class='gform_hidden' name='is_submit_31' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='31' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_31' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_31' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_31' value='WyJbXSIsIjNlOGU2ZTE2ZDhkYmI1MzkwZDhmZjU2MGI1OTViMzA4Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_31' id='gform_target_page_number_31' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_31' id='gform_source_page_number_31' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 31, 'https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_31').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_31');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_31').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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If you are concerned this page may time out before you are able to complete the form, or if you are unable to complete the form in one sitting, you can save your progress by clicking the \u201cSave and continue later.\u201d text at the bottom of the form.<br \/>\n\t\t\t\t\t\t\t&quot;*&quot; indicates required fields<\/p>\n<p>                        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 &#038; Medicaid Services, Mountain Pacific works with local, state and national partners to achieve quality improvement\u2014and 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:Name *  Required Title\/Role Email *  Required<\/p>\n<p>                        Phone *  RequiredOrganization Name Organization Type Address *  Required    <\/p>\n<p>                                        Street Address<\/p>\n<p>                                        Address Line 2<\/p>\n<p>                                    City<\/p>\n<p>                                        State \/ Province \/ Region<\/p>\n<p>                                    ZIP \/ Postal Code<\/p>\n<p>                                        AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCura\u00e7aoCyprusCzechiaC\u00f4te d&#039;IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People&#039;s Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People&#039;s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaR\u00e9unionSaint Barth\u00e9lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluT\u00fcrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe\u00c5land Islands<br \/>\n                                        Country<\/p>\n<p>                Secondary Contact Information:Name Title\/Role Email<\/p>\n<p>                        PhoneQuestionsWhere can you use our support? (Check all that apply.)<\/p>\n<p>\t\t\t\t\t\t\t\tOpioid Use and Misuse<\/p>\n<p>\t\t\t\t\t\t\t\tCare Coordination<\/p>\n<p>\t\t\t\t\t\t\t\tHealth Equity<\/p>\n<p>\t\t\t\t\t\t\t\tImprove Nursing Home Quality<\/p>\n<p>\t\t\t\t\t\t\t\tChronic Disease Management<\/p>\n<p>\t\t\t\t\t\t\t\tImmunizations<\/p>\n<p>\t\t\t\t\t\t\t\tEmergency Preparedness<\/p>\n<p>\t\t\t\t\t\t\t\tOther (We will contact you!)<br \/>\n\t\t\t\t\t\t\tMountain 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\u2019s 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<\/p>\n<p>\t\t\t\t\tYes<\/p>\n<p>\t\t\t\t\tNo (If you answer No, your organization is still eligible to participate.)<br \/>\n\t\t\tThis participation agreement between your organization and Mountain-Pacific Quality Health is in effect through November 2024.<\/p>\n<p>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<br \/>\nHelena, MT 59604.<br \/>\n<a href=\"https:\/\/www.mpqhf.org\/QIO\/wp-content\/uploads\/2022\/08\/Community-Participation-Agreement-August-2022-508.pdf\">Community Partnership Participation Agreement PDF<\/a><\/p>\n<p>           Save and continue later.<\/p>\n","protected":false},"author":10,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"class_list":["post-269250","page","type-page","status-publish","entry"],"_links":{"self":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/pages\/269250"}],"collection":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/users\/10"}],"replies":[{"embeddable":true,"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/comments?post=269250"}],"version-history":[{"count":0,"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/pages\/269250\/revisions"}],"wp:attachment":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/media?parent=269250"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}