IHC Information Form

Thank you for your interest in Integrated Health Collaborative, LLC (IHC). IHC is a physician led Clinically Integrated Network/Accountable Care Organization comprised of hospitals and physicians who work together to implement evidence based practices, eliminate unnecessary variation, improve coordination of care, and share data that enables patient centered performance improvement in quality, clinical outcomes, and efficiency and cost of care for our population.

Please complete the form below and an IHC representative will contact you.

Form Completed By Form Completed By First Last
Position
Phone Number Phone Number - ### - ### ####
Practice Name
Primary Practice Address Primary Practice Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Are you a solo practice?

Are you a solo practice? Yes No

Please note that all members of your group practice must be eligible for membership and all members must participate in the clinically integrated network in order for you to participate.
How did you hear about the IHC?