PA Health & Wellness Nursing Facility Program Enrollment

We are excited that your organization will be participating in the Real Time program, which will support the PA Health & Wellness Nursing Facility Shared Savings Program.

Please complete the form below so that we can expedite your Real Time agreement to begin participation in the program.

If you have any questions, please contact [email protected].

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Corporate Name*
List all facilities that will be enrolled in the PA Health & Wellness Nursing Facility Shared Savings Program.*
How would you organization prefer to receive the Real Time agreement?*
- Please send one agreement, with all facilities listed.
- Please send individual agreements for each facility.
Which EHR is your organization currently utilizing?*
CONTRACT SIGNATORY
CONTRACT SIGNATORY: Please list the appropriate contact that should receive and sign the Real Time agreement.
Name*
First Last
Title*
Email*
Phone*
Additional Information
Please provide any additional information within this section, including additional contacts from your organization that should receive the Real Time agreement (name, title, and email).
SUBMITTER INFORMATION
SUBMITTER INFORMATION: If you are not the contract signatory, please complete the following fields and we will contact you once the contract has been sent.
Name
Email
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PA Health & Wellness Nursing Facility Program Enrollment

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CONTRACT SIGNATORY

SUBMITTER INFORMATION

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