{"id":304998,"date":"2024-10-03T10:16:46","date_gmt":"2024-10-03T16:16:46","guid":{"rendered":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/?page_id=304998"},"modified":"2024-10-03T10:16:46","modified_gmt":"2024-10-03T16:16:46","slug":"alaska-community-partnership-participation","status":"publish","type":"page","link":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/alaska-community-partnership-participation\/","title":{"rendered":"Alaska 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_38' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Alaska Community Partnership Participation Agreement (Alaska only)<\/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_38'  action='\/QIO\/wp-json\/wp\/v2\/pages\/304998' data-formid='38' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_38' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_38_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_38_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_38_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_38_13\" ><h3 class=\"gsection_title\">Primary Contact Information:<\/h3><\/div><div id=\"field_38_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_38_1\" ><label class='gfield_label gform-field-label' for='input_38_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_38_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_38_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_38_18\" ><label class='gfield_label gform-field-label' for='input_38_18'>Title\/Role<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_38_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_38_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_38_3\" ><label class='gfield_label gform-field-label' for='input_38_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_38_3' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_38_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_38_4\" ><label class='gfield_label gform-field-label' for='input_38_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_38_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_38_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_38_5\" ><label class='gfield_label gform-field-label' for='input_38_5'>Organization Name<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_38_5' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_38_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_38_6\" ><label class='gfield_label gform-field-label' for='input_38_6'>Organization Type<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_38_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_38_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_38_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_zip ginput_container_address gform-grid-row' id='input_38_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_38_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_38_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_38_7_1' id='input_38_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_38_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_38_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_38_7_2' id='input_38_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_38_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_38_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_38_7_3' id='input_38_7_3_label' class='gform-field-label gform-field-label--type-sub '>City in Alaska<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_7.4' id='input_38_7_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_38_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_38_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_38_7_5' id='input_38_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_38_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/fieldset><div id=\"field_38_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_38_19\" ><h3 class=\"gsection_title\">Secondary Contact Information:<\/h3><\/div><div id=\"field_38_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_38_21\" ><label class='gfield_label gform-field-label' for='input_38_21'>Name<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_38_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_38_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_38_20\" ><label class='gfield_label gform-field-label' for='input_38_20'>Title\/Role<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_38_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_38_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_38_22\" ><label class='gfield_label gform-field-label' for='input_38_22'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_38_22' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_38_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_38_23\" ><label class='gfield_label gform-field-label' for='input_38_23'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_38_23' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_38_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_38_14\" ><h3 class=\"gsection_title\">Questions<\/h3><\/div><fieldset id=\"field_38_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_38_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_38_9'><div class='gchoice gchoice_38_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_38_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_1' id='label_38_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_38_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_38_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_2' id='label_38_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_38_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_38_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_3' id='label_38_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_38_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_38_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_4' id='label_38_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_38_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_38_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_5' id='label_38_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_38_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_38_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_6' id='label_38_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_38_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_38_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_7' id='label_38_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_38_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_38_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_38_9_8' id='label_38_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_38_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_38_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_38_17'>\n\t\t\t<div class='gchoice gchoice_38_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_38_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_38_17_0' id='label_38_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_38_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_38_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_38_17_1' id='label_38_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_38_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_38_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_38' class='gform_button button' value='Submit Agreement'  onclick='if(window[\"gf_submitting_38\"]){return false;}  if( !jQuery(\"#gform_38\")[0].checkValidity || jQuery(\"#gform_38\")[0].checkValidity()){window[\"gf_submitting_38\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_38\"]){return false;} if( !jQuery(\"#gform_38\")[0].checkValidity || jQuery(\"#gform_38\")[0].checkValidity()){window[\"gf_submitting_38\"]=true;}  jQuery(\"#gform_38\").trigger(\"submit\",[true]); }' \/> <button type='button'  id='gform_save_38_footer_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_38\"]){return false;}  if( !jQuery(\"#gform_38\")[0].checkValidity || jQuery(\"#gform_38\")[0].checkValidity()){window[\"gf_submitting_38\"]=true;} jQuery(\"#gform_save_38\").val(1); jQuery(\"#gform_38\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_38\"]){return false;} if( !jQuery(\"#gform_38\")[0].checkValidity || jQuery(\"#gform_38\")[0].checkValidity()){window[\"gf_submitting_38\"]=true;} jQuery(\"#gform_save_38\").val(1); jQuery(\"#gform_38\").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_38' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='38' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_38' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_38' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_38' value='WyJbXSIsIjNlOGU2ZTE2ZDhkYmI1MzkwZDhmZjU2MGI1OTViMzA4Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_38' id='gform_target_page_number_38' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_38' id='gform_source_page_number_38' 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( 38, 'https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_38').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_38');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_38').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 in Alaska<\/p>\n<p>                                    ZIP Code<\/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":17,"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-304998","page","type-page","status-publish","entry"],"_links":{"self":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/pages\/304998"}],"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\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/comments?post=304998"}],"version-history":[{"count":0,"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/pages\/304998\/revisions"}],"wp:attachment":[{"href":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/wp-json\/wp\/v2\/media?parent=304998"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}