E-Collaborative
21st Century Patient Care and Self-Management wave

Expression of Interest form

Please complete this form to register your interest for the E-Collaborative 21st Century Patient Care and Self-Management wave.

Practice Name*:

Division/Medicare Local/NACCHO Affiliate Name*:

Street Address*:

Suburb*:

State*: Please select ACT NSW NT QLD SA TAS VIC WA

Postcode*:

Postal Address:

Suburb:

State: Please select ACT NSW NT QLD SA TAS VIC WA

Postcode:

Phone Number*:

Fax Number:

Contact Name*:

Position*:

Email Address*:

Mobile Number:

Accredited: Please select Yes No

Accreditation: Please select AGPAL GPA

Organisation Type: Please select AMS General Practice Corporate Practice Solo Practice Community Health

Clinical Software:

Billing Software:

We would like to advise your Division of General Practice, Medicare Local or NACCHO Affiliate about your interest in the E-Collaborative. This will help us make support arrangements for this wave. Please tick if you do not want IF to make this contact.

^*fields marked with an asterix are required.

Places are limited and the closing date for expressions of interest is Thursday 24 November 2011.

IF will advise by Wednesday 30 November if your application has been successful.