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PHYSICIANS REACH OUT COMMITMENT FORM
PRACTICE: SPECIALTY:
ADDRESS:
PHONE: FAX:
EMAIL: WEBSITE:
IS YOUR PRACTICE ON FACEBOOK: YES NO IS YOUR PRACTICE ON TWITTER: YES NO
ACCOUNT:
YES! Our practice will agree to volunteer with Physicians Reach Out.
Each physician will see _________ patients per year for services.
Physicians usually accept an average of one patient/month for family practice/internal medicine
or two patients/month for specialists. MLPs may also volunteer in PRO.
Please complete this form and fax to 704-943-3747. If you have any questions, please contact
our Provider Liaison at 704-248-3739 or Scameron@CareRingNC.com
(Please Print - Name of Practice Manager/Administrator or Lead Physician)
Signature Date
PHYSICIAN/PROVIDER NAME PHYSICIAN/PROVIDER NAME
Where do you have hospital privileges? PRO OFFICE USE:
Date Received: __________________
Atrium Novant Both Atrium and Novant Date Entered: ___________________
Entered by: _____________________
Number of commitments per physician: ___________ Date Scanned: __________________
Monthly Bi-monthly Quarterly Yearly
THANK YOU!
Mecklenburg Medicine • January 2019 | 7
