Population Health Incentive Program Interest Form

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class="collapse" id="group-3fa95ebc1-f27a-4415-bc3c-0765efa59935"> <a href="https://www.hpsm.org/provider/resources/language-services/language-training-resources/provider-language-assistance-checklist" class="list-group-item strong "> Provider Language Assistance Checklist </a> </div> </div> <a href="https://www.hpsm.org/provider/resources/forms" class="list-group-item dropdown-item collapsed "> Provider Forms <i href="#group-2cc4a9fcf-89a8-400d-8861-036fff50a4a7" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-2cc4a9fcf-89a8-400d-8861-036fff50a4a7"> <a href="https://www.hpsm.org/update-my-information" class="list-group-item strong "> Update My Information </a> </div> <a href="https://www.hpsm.org/provider/directory-search" class="list-group-item strong "> Directory Search </a> <a href="https://www.hpsm.org/provider/formulary-search" class="list-group-item strong "> Formulary Search </a> <a href="https://www.hpsm.org/provider/resources/diabetes-prevention-program" class="list-group-item dropdown-item collapsed "> Diabetes Prevention Program <i href="#group-256465877-c942-4d46-ac8e-5ddd06ccea2c" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-256465877-c942-4d46-ac8e-5ddd06ccea2c"> <a href="https://www.hpsm.org/provider/resources/diabetes-prevention-program/dpp-patient-referral-form" class="list-group-item strong "> DPP Patient Referral Form </a> <a href="https://www.hpsm.org/provider/resources/diabetes-prevention-program/smmc-diabetes-program" class="list-group-item strong "> SMMC Diabetes Program </a> </div> <a href="https://www.hpsm.org/provider/resources/end-of-life-care" class="list-group-item strong "> End of Life Care </a> <a href="https://www.hpsm.org/provider/resources/grievance-appeals-process" class="list-group-item dropdown-item collapsed "> Grievance & Appeals Process <i href="#group-2b3455ac9-2dbe-49d9-8122-e8aa4896b81a" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-2b3455ac9-2dbe-49d9-8122-e8aa4896b81a"> <a href="https://www.hpsm.org/provider/resources/grievance-appeals-process/what-is-a-complaint" class="list-group-item strong "> What is a complaint? </a> <a href="https://www.hpsm.org/provider/resources/grievance-appeals-process/providers-responsibilities" class="list-group-item strong "> Providers’ responsibilities </a> <a href="https://www.hpsm.org/provider/resources/grievance-appeals-process/response-timeframes" class="list-group-item strong "> Response timeframes </a> <a href="https://www.hpsm.org/provider/resources/grievance-appeals-process/contact-g-a-unit" class="list-group-item strong "> Contact HPSM's G&A Unit </a> </div> <a href="https://www.hpsm.org/provider/resources/healthcare-effectiveness-data-and-information-set" class="list-group-item strong "> Healthcare Effectiveness Data and Information Set </a> <a href="https://www.hpsm.org/provider/resources/home-health-care" class="list-group-item strong "> Home Health Care </a> <a href="https://www.hpsm.org/provider/resources/initial-health-assessment" class="list-group-item dropdown-item collapsed "> Initial Health Appointment <i href="#group-26a1fa7ee-3bb9-43c0-9906-a87e96f3a1a2" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-26a1fa7ee-3bb9-43c0-9906-a87e96f3a1a2"> <a href="https://www.hpsm.org/provider/resources/initial-health-assessment/2023-iha-changes" class="list-group-item strong "> 2023 IHA Changes </a> </div> <a href="https://www.hpsm.org/provider/resources/maternal-health" class="list-group-item strong "> Maternal Care </a> <a href="https://www.hpsm.org/provider/resources/medical-record-and-facility-site-reviews" class="list-group-item strong "> Medical Record and Facility Site Reviews </a> <a href="https://www.hpsm.org/provider/resources/member-handbooks" class="list-group-item strong "> Member Handbooks </a> <a href="https://www.hpsm.org/provider/resources/healthmatters-md" class="list-group-item dropdown-item collapsed "> HEALTHmatters MD <i href="#group-2d14f87bd-a03d-43fe-a11c-bb7bbda4fbb3" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-2d14f87bd-a03d-43fe-a11c-bb7bbda4fbb3"> <a href="https://www.hpsm.org/provider/resources/healthmatters-md/newsletters" class="list-group-item strong "> Newsletter Archive </a> <a href="https://www.hpsm.org/provider/resources/healthmatters-md/provider-notices" class="list-group-item strong "> Provider Notices </a> </div> <a href="https://www.hpsm.org/provider/resources/pediatric-care" class="list-group-item strong "> Pediatric Care </a> <a href="https://www.hpsm.org/provider/resources/potential-quality-issues" class="list-group-item strong "> Potential Quality Issues </a> <a href="https://www.hpsm.org/provider/resources/urgent-care" class="list-group-item strong "> Urgent Care </a> <a href="https://www.hpsm.org/provider/resources/tobacco-cessation-resources" class="list-group-item dropdown-item collapsed "> Tobacco Cessation Information and Resources <i href="#group-2a2e64e2f-647c-4816-96ef-61c922e9f031" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-249fc1852-db3d-4a9d-b8ef-a398dd5edc32"></i> </a> <div class="collapse" id="group-2a2e64e2f-647c-4816-96ef-61c922e9f031"> <a href="https://www.hpsm.org/provider/resources/tobacco-cessation-resources/identifying-tobacco-users" class="list-group-item strong "> Identifying Tobacco Users </a> <a href="https://www.hpsm.org/provider/resources/tobacco-cessation-resources/treating-patients-who-use-tobacco" class="list-group-item strong "> Treating Patients Who Use Tobacco </a> <a href="https://www.hpsm.org/provider/resources/tobacco-cessation-resources/vulnerable-populations" class="list-group-item strong "> Vulnerable Populations </a> <a href="https://www.hpsm.org/provider/resources/tobacco-cessation-resources/provider-education-and-trainings" class="list-group-item strong "> Provider Education and Trainings </a> </div> <a href="https://www.hpsm.org/provider/resources/older-adults-and-persons-with-disabilities" class="list-group-item strong "> Older Adults and People with Disabilities </a> <a href="https://www.hpsm.org/provider/videos" class="list-group-item strong "> Provider Videos </a> <a href="https://www.hpsm.org/provider/resources/remote-patient-monitoring" class="list-group-item strong "> Remote Patient Monitoring </a> </div> <a href="https://www.hpsm.org/provider/care-coordination" class="list-group-item strong "> Care Coordination </a> <a href="https://www.hpsm.org/provider/behavioral-health" class="list-group-item strong "> Behavioral Health </a> <a href="https://www.hpsm.org/provider/incentive-payments" class="list-group-item dropdown-item collapsed "> Provider Incentive Programs <i href="#group-120d1dcb7-63c0-4f34-80c4-9114c53527ed" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-135bd4b25-8293-494c-84ae-6452bf4545bb"></i> </a> <div class="collapse" id="group-120d1dcb7-63c0-4f34-80c4-9114c53527ed"> <a href="https://www.hpsm.org/provider/incentive-payments/incentive-payments-for-primary-care-providers" class="list-group-item dropdown-item collapsed "> Incentives for Primary Care Providers <i href="#group-268f151c5-4ff8-46cb-a0d0-b9162ad1b71a" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-220d1dcb7-63c0-4f34-80c4-9114c53527ed"></i> </a> <div class="collapse" id="group-268f151c5-4ff8-46cb-a0d0-b9162ad1b71a"> <a href="https://www.hpsm.org/provider/incentive-payments/incentive-payments-for-primary-care-providers/care-gap-p4p-incentive-program-interest-form" class="list-group-item strong active"> Care Gap P4P Incentive Program Interest Form </a> </div> <a href="https://www.hpsm.org/provider/incentive-payments/incentive-payments-for-nursing-facilities" class="list-group-item strong "> Incentives for Nursing Facilities </a> <a href="https://www.hpsm.org/provider/incentive-payments/incentive-payments-for-specialists" class="list-group-item strong "> Incentives for Specialty Providers  </a> </div> <a href="https://www.hpsm.org/provider/learning-lab" class="list-group-item strong "> Learning Lab </a> <a href="https://www.hpsm.org/provider/sb855-training-request" class="list-group-item strong "> SB855 Training Request </a> <a href="https://www.hpsm.org/provider/hpsm-dental" class="list-group-item dropdown-item collapsed "> HPSM Dental Providers <i href="#group-174f36575-3241-48b1-9e76-4b1c1d28f8cf" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-135bd4b25-8293-494c-84ae-6452bf4545bb"></i> </a> <div class="collapse" id="group-174f36575-3241-48b1-9e76-4b1c1d28f8cf"> <a href="https://www.hpsm.org/provider/hpsm-dental/join-hpsm-dental" class="list-group-item dropdown-item collapsed "> Join HPSM Dental <i href="#group-2388b7643-c933-4415-be9e-c964394a836a" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-274f36575-3241-48b1-9e76-4b1c1d28f8cf"></i> </a> <div class="collapse" id="group-2388b7643-c933-4415-be9e-c964394a836a"> </div> <a href="https://www.hpsm.org/provider/hpsm-dental/payments" class="list-group-item strong "> Dental Provider Payments </a> <a href="https://www.hpsm.org/provider/hpsm-dental/covered-dental-services" class="list-group-item strong "> Covered Dental Services </a> <a href="https://www.hpsm.org/provider/hpsm-dental/benefits-of-dental-integration" class="list-group-item strong "> Benefits of Dental Integration </a> <a href="https://www.hpsm.org/provider/hpsm-dental/mission" class="list-group-item strong "> HPSM Dental Mission </a> <a href="https://www.hpsm.org/provider/hpsm-dental/an-innovative-pilot-program" class="list-group-item strong "> An Innovative Pilot Program </a> </div> <a href="https://www.hpsm.org/provider/patient-experience" class="list-group-item strong "> Patient Experience </a> <a href="https://www.hpsm.org/provider/calaim-at-hpsm" class="list-group-item dropdown-item collapsed "> CalAIM at HPSM <i href="#group-167f12e56-7522-48b7-aaa7-68b7a007b163" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-135bd4b25-8293-494c-84ae-6452bf4545bb"></i> </a> <div class="collapse" id="group-167f12e56-7522-48b7-aaa7-68b7a007b163"> <a href="https://www.hpsm.org/provider/calaim-at-hpsm/enhanced-care-management-(ecm)" class="list-group-item strong "> Enhanced Care Management (ECM) </a> <a href="https://www.hpsm.org/provider/calaim-at-hpsm/community-supports-(cs)" class="list-group-item strong "> Community Supports (CS) </a> </div> <a href="https://www.hpsm.org/provider/urgent-messages" class="list-group-item dropdown-item collapsed "> Urgent Messages <i href="#group-15bc380af-3a0c-4750-aba7-b97106a561bd" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-135bd4b25-8293-494c-84ae-6452bf4545bb"></i> </a> <div class="collapse" id="group-15bc380af-3a0c-4750-aba7-b97106a561bd"> <a href="https://www.hpsm.org/provider/urgent-messages/provider-covid-19-resources" class="list-group-item strong "> Provider COVID-19 Resources </a> <a href="https://www.hpsm.org/provider/urgent-messages/monkeypox" class="list-group-item dropdown-item collapsed "> Mpox (Monkeypox) <i href="#group-2bf4fc89c-c2e8-4a7b-8c2e-fa99faed8e19" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-25bc380af-3a0c-4750-aba7-b97106a561bd"></i> </a> <div class="collapse" id="group-2bf4fc89c-c2e8-4a7b-8c2e-fa99faed8e19"> </div> <a href="https://www.hpsm.org/provider/urgent-messages/prepare-for-power-shutoffs" class="list-group-item strong "> Prepare for Power Shutoffs </a> </div> <a href="https://www.hpsm.org/provider/news" class="list-group-item strong "> News & Updates </a> <a href="https://www.hpsm.org/provider/portal" class="list-group-item strong "> Provider Portal / eReports </a> <a href="https://www.hpsm.org/provider/join-the-network" class="list-group-item strong "> Join Our Provider Network </a> <a href="https://www.hpsm.org/provider/contact-provider-services" class="list-group-item dropdown-item collapsed "> Provider Contacts <i href="#group-1e0265f57-f2de-4917-b33c-849c70bc8164" class="fa fa-caret-down collapsed" data-toggle="collapse" data-parent="group-135bd4b25-8293-494c-84ae-6452bf4545bb"></i> </a> <div class="collapse" id="group-1e0265f57-f2de-4917-b33c-849c70bc8164"> <a href="https://www.hpsm.org/provider/contact/nomination-form" class="list-group-item strong "> Nominate a Colleague </a> </div> <a href="https://www.hpsm.org/provider/all-tasks" class="list-group-item strong "> All Provider Tasks </a> </div> </div> </div> <div class="related-items">  <div class="card"> <h3> </h3> <div class="name-and-phone-list"> <h5> </h5> </div> <div class="name-and-phone-list"> <h5> </h5> </div> <div class="name-and-phone-list"> <h5> </h5> </div> </div> </div> </div> <div class="col-xs-12 col-sm-8 col-sm-pull-4"> <div class="content-area container-fluid-margin"> <div class="plan-name mb-4"> <a href="/provider">Provider </a> <span> / </span> <a href="/provider/incentive-payments">Provider Incentive Programs </a> <span> / </span> <a href="/provider/incentive-payments/incentive-payments-for-primary-care-providers">Incentives for Primary Care Providers </a> </div><div class="sf_cols" data-sf-element="Row"> <div class="sf_colsOut sf_1col_1_100"> <div id="Contentplaceholder_TACCE306D001_Col00" class="sf_colsIn sf_1col_1in_100" data-sf-element="Column 1"> </div> </div> </div> <div > <div class="sfContentBlock sf-Long-text" ><h1>Care Gap Closure P4P Incentive Interest Form</h1></div> </div><div data-sf-role="form-container" class="hpsm-form"> <input type="hidden" data-sf-role="form-id" value="5b982e30-6b11-411c-ba8e-585e484cd0a9" name="FormId" /> <input type="hidden" data-sf-role="marketo-settings" value="{"syncFormFieldsToLeadFields":false,"doSpecificWebCalls":false}" name="MarketoSettings" /> <form action="/provider/incentive-payments/incentive-payments-for-primary-care-providers/care-gap-p4p-incentive-program-interest-form?sf_cntrl_id=ctl00%24Contentplaceholder%24C005" method="POST" name="defaultFormctl00$Contentplaceholder$C005" enctype="multipart/form-data" role="form"> <div > <div class="sfContentBlock sf-Long-text" ><div class="space-1"><p>Providers may begin accessing the Care Gap Closure P4P program through the Stellar platform on February 1, 2024. Providers must participate in an onboarding call with the Stellar team to gain access. All contracted primary care clinics will receive scheduling outreach from Stellar between December 2023 – June 2024. Use this form to indicate that you would like to receive priority outreach from Stellar.</p><p>If you are not an HPSM contracted primary care provider, please complete our <a href="https://providers.hpsm.org/ProviderIntake/">provider intake form</a> before filling out the form below. </p></div></div> </div> <div class="contracted-pcp w-100 sf-fieldWrp sf-RadioButtons" data-sf-role="multiple-choice-field-container"> <input type="hidden" data-sf-role="violation-messages" value='{ "required": "You must be an HPSM-contracted primary care provider to enroll in Stellar", "maxLength":"I am a contracted primary care provider: field must be less than 255 characters"}' /> <strong>I am a contracted primary care provider:</strong> <label> <input type="radio" name="MultipleChoiceFieldController" value="Yes" data-sf-role="multiple-choice-field-input" required="required" pattern=".{0,255}" /> Yes </label> <label> <input type="radio" name="MultipleChoiceFieldController" value="No" data-sf-role="multiple-choice-field-input" required="required" pattern=".{0,255}" /> No </label> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> <div id="C007_Col00" class="sf_colsIn container" data-sf-element="Container"> <div class="sf_colsOut sf_2cols_1_50"> <div id="C123_Col00" class="sf_colsIn sf_2cols_1in_50" data-sf-element="Column 1"> <div class="text-field name-field sf-fieldWrp" data-sf-role="text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Provider's name: field must be less than 255 characters", "required": "Provider's name: field input is required", "invalid": "Entry is not valid!", "regularExpression": "Provider's name: field input is invalid"}' /> <label for='Textbox-1'>Provider's name:</label> <input id='Textbox-1' data-sf-role="text-field-input" type="text" name="TextFieldController_6" placeholder="First and last name" value="" required="required" pattern=".{0,255}" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div class="sf_colsOut sf_2cols_2_50"> <div id="C123_Col01" class="sf_colsIn sf_2cols_2in_50" data-sf-element="Column 2"> <div class="text-field name-field sf-fieldWrp" data-sf-role="text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Your name: field must be less than 255 characters", "required": "Your name: field input is required", "invalid": "Entry is not valid!", "regularExpression": "Your name: field input is invalid"}' /> <label for='Textbox-2'>Your name:</label> <input id='Textbox-2' data-sf-role="text-field-input" type="text" name="TextFieldController_6_0" placeholder="If different from provider's name" value="" pattern=".{0,255}" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div > <div class="sfContentBlock sf-Long-text" ><div class="clearfix"></div></div> </div><div class="sf_colsOut sf_2cols_1_50"> <div id="C008_Col00" class="sf_colsIn sf_2cols_1in_50" data-sf-element="Column 1"> <div class="text-field sf-fieldWrp" data-sf-role="text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Group NPI: field must be less than 255 characters", "required": "Group NPI: field input is required", "invalid": "Entry is not valid!", "regularExpression": "Group NPI: field input is invalid"}' /> <label for='Textbox-3'>Group NPI:</label> <input id='Textbox-3' data-sf-role="text-field-input" type="text" name="TextFieldController_5" value="" required="required" pattern=".{0,255}" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div class="sf_colsOut sf_2cols_2_50"> <div id="C008_Col01" class="sf_colsIn sf_2cols_2in_50" data-sf-element="Column 2"> <div class="text-field sf-fieldWrp" data-sf-role="email-text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Email: field must be less than 255 characters", "required": "Email address is required", "invalid": "Entry is not valid!", "regularExpression": "Email address is invalid"}' /> <label for='Email-1'>Email:</label> <input id='Email-1' data-sf-role="email-text-field-input" type="email" name="EmailTextFieldController" value="" required="required" pattern="^[a-zA-Z0-9.!#$%&'*\+\-/=?^_`{|}~]+@(?:[a-zA-Z0-9-]+\.)+[a-zA-Z]{2,63}$" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div > <div class="sfContentBlock sf-Long-text" ><div class="clearfix"></div></div> </div><div class="sf_colsOut sf_2cols_1_50"> <div id="C014_Col00" class="sf_colsIn sf_2cols_1in_50" data-sf-element="Column 1"> <div class="text-field phone-field sf-fieldWrp" data-sf-role="text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Phone: field must be less than 255 characters", "required": "Phone: field input is required", "invalid": "Entry is not valid!", "regularExpression": "Phone: field input is invalid"}' /> <label for='Textbox-4'>Phone:</label> <input id='Textbox-4' data-sf-role="text-field-input" type="text" name="TextFieldController" value="" required="required" pattern=".{0,255}" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div class="sf_colsOut sf_2cols_2_50"> <div id="C014_Col01" class="sf_colsIn sf_2cols_2in_50" data-sf-element="Column 2"> <div class="text-field phone-field sf-fieldWrp" data-sf-role="text-field-container"> <input data-sf-role="violation-restrictions" type="hidden" value='{"maxLength":"255", "minLength": "0"}' /> <input data-sf-role="violation-messages" type="hidden" value='{"maxLength":"Fax: field must be less than 255 characters", "required": "Fax: field input is required", "invalid": "Entry is not valid!", "regularExpression": "Fax: field input is invalid"}' /> <label for='Textbox-5'>Fax:</label> <input id='Textbox-5' data-sf-role="text-field-input" type="text" name="TextFieldController_8" value="" pattern=".{0,255}" /> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> </div> </div> <div class="sf_colsOut sf_1col_1_100"> <div id="C090_Col00" class="sf_colsIn sf_1col_1in_100" data-sf-element="Column 1"> <div data-sf-role="field-captcha-container" style="display:none;" class="space-1 sf-fieldWrp"> <div> <img data-sf-role="captcha-image" src='/Frontend-Assembly/Telerik.Sitefinity.Frontend/assets/dist/img/dummy.jpg'/> <button data-sf-role="captcha-audio-btn" type="button">Read the code</button> <audio data-sf-role="captcha-audio" controls style="display:none" /> </div> <a data-sf-role="captcha-refresh-button">New code</a> <div> <input data-sf-role="violation-messages" type="hidden" value='{"required": "Captcha field input is required"}' /> <label for='Textbox-6'>Please type the code above</label> <input id='Textbox-6' type="text" data-sf-role="captcha-input" name="captcha-a" required='required'/> <p data-sf-role="error-message" role="alert" aria-live="assertive"></p> </div> <input type="hidden" data-sf-role="captcha-k" name="captcha-k" /> <input type="hidden" data-sf-role="captcha-settings" value="/RestApi/captcha/" /> <input type="hidden" data-sf-role="captcha-iam" value='Incorrect value for the captcha image' /> </div> <div class="hpsm-form-nav sf-fieldWrp"> <button 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