Medical Provider Application – Ginn Group Collaborative

Medical Provider Partner Candidate Application
for SMART Student Health and Wellness Center Implementation

Thank you for your interest in becoming a SMART Clinic Medical Provider Partner.

Please complete the below application. We welcome the opportunity to learn about you, your qualifications, and how becoming a SMART Clinic Medical Provider Partner aligns with your goals.

Once your application is received a member of our team will follow up with you within 2-3 business days.

Name of Organization*
Address*
Street Address Address Line 2 City State ZIP Code
Name and Title of Key Contact or Liaison*
Contact Email*
Contact Phone Number*
Name of Organization's CEO*
Is your organization a Federally Qualified Health Center (FQHC)/FQHC-Look-a-like/Rural Health Center (RHC), or any other form of enhanced rate credentialing?*
Do you operate any type of in-school clinic, or have you operated any type of in-school clinic in the past?*
- Yes
- No
If yes, what are or were the dates of operation?
If yes, what is or was the utilization rate and financial sustainability level?
Please describe your mission, corporate imperatives, and culture:*
How many clinics/hospitals does your organization operate?*
What is your annual operating budget?*
Please list your encounter rates for Behavioral Health Services.*
Please list your encounter rates for Medical Services.*
How is your organization involved in your local schools (past or current)?*
What are the biggest challenges facing your organization and reaching the student population and their families in your community?*
Please tell us how you learned about the SMART Model and how you hope it can support better outcomes for your organization:*
Please describe, in detail, the current health services and specialties being provided by your organization:*
Do you provide dental health services?*
Do you provide any integrative health interventions? Please describe.*
What, if any, specialty services does your organization provide your patients? (i.e., OB/GYN, orthopedic, dermatology, cardiology, pulmonology, endocrinology, etc.)*
What areas do you refer out?*
Do you have any internal residential programs that you send your providers through for training?*
What speciality services (ie. wound care, OB/GYN) are covered outside of your primary care providers?*
What Electronic Health Record (EHR) System do you use?*
If selected as the SMART Medical Provider Partner in your community, who has the authority to implement it as a distinct department with a unique scope of work within your organization? Who are the key stakeholders, and is there a formal decision-making process within your organization?*
If selected, what barriers or challenges do you anticipate will need to be overcome for the success of the SMART Model as an embedded partner with your organization?*
Please include anything else you want us to know about your organization:
Please attach your organizational chart with executive structure, a copy of your latest annual report, a bio on the CEO, and how long they have been there.
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Medical Provider Partner Candidate Application for SMART Student Health and Wellness Center Implementation

Medical Provider Partner Candidate Application
for SMART Student Health and Wellness Center Implementation