To learn more about the ADC Program and becoming a potential dissemination site, please complete the Interest Form below and someone will be in contact within 48 hours to schedule an initial telephone meeting.

Name of Organization *

Address of Organization *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Organization Website

http://

Description of Organization

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 of your organization's EMR *

Organization's Primary Contact for ADC Program Interest

Name *

First Name

Last Name

Title *

Email Address *

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

What is your prior experience working in Alzheimer's and Dementia care? *

How is your organization currently handling dementia care? *

How did you hear about the UCLA ADC Program? *

Dementia Care Aware

Colleague

Newscast / Press release

Blog / Podcast

Affinity Group

Journal article

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

Professional meeting, specify below

Other, specify below

Are you a CMS GUIDE Participant?

Yes - Established Participant

Yes - New Participant

Thank you!

Generously supported by

info@adcprogram.org

ADC Program Interest Form

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