ADC Program Interest Form

Address of Organization *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organization Type *

Health Plan

Community-based Organization

Large Medical Group

Small Medical Group

Non-academic Health Center

Academic Health Center, specify below:

Other, specify below:

Organization Population *

Urban

Rural

Organization Ownership *

Private, for profit

Private, nonprofit

Government, Federal

Government, VA

Government, County

Government, State

Other, specify below

Name *

First Name

Last Name

Phone *

(###)

###

####

Role in Organization (check the one the best describes your role) *

Physician

Advance Practice Provider

Clinic Manager

Department Lead

Executive

Staff

Board Member

Other, specify below

How did you hear about the UCLA ADC Program? *

Dementia Care Aware

Colleague

Newscast / Press release

Blog / Podcast

Website (AGS, Alzheimer's Association, GAPNA, etc.)

Journal article

Professional meeting, specify below

Other, specify below

Did your site submit an RFA for CMS's GUIDE Model?

Yes

No

Not Sure