AHRQ Medical Liability Reform and Patient Safety Demonstration Project

Expression of Interest to Sponsor an AHRQ Medical Liability Reform and Patient Safety Demonstration Project to Test the MedEncentive Program

To confirm your interest in partnering with MedEncentive to submit an application for an AHRQ Medical Liability Reform and Patient Safety Demonstration Project, complete the information in this form by December 16, 2009.

Name of organization: *
Address:
City:
Postal Code:
State:
Name/Title Primary Contact: *
Telephone: *
E-Mail: *
Fax:
List the names of potential employers and health plans for the demonstration:
Comments:
Type of Organization (refer to AHRQ Funding Opportunity for more information on the qualifications for sponsoring organizations): *
State Government (Please Describe)
units of State governments (Please Describe)
coalitions of State governments (Please Describe)
established associations of State governments (Please Describe)
Established health care system

Employers

Insurers

Doctors

Patients

Brokers & Consultants

Plan Administrators

Partners