Request to Join the UW Medicine ACN

Thank you for your interest in the UW Medicine Accountable Care Network (ACN). Please fill out the following form to assist us in evaluating your request based on our network adequacy and other additional criteria.

Note: Boeing product is now closed to new provider groups.

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Clinic Information
Contact Information
Provider Information
Clinic's Electronic Health Record (EHR), if applicable
Which product is the clinic interested in participating in (select all that apply)?

Note: Boeing product is now closed to new provider groups.

There was a problem in creating or sending your request. Please see the instructions in the introduction for manually following up with this.

Thank you for submitting your Clinic information for inclusion in the UW Medicine ACN. Someone will reply to your request soon.

Thank you for submitting your Clinic. The form will reload and the contact data elements from the last submit will be maintained for your convenience in submitting additional ones.

Please review - Some of the information you have entered did not match the requirements.

Thank you for considering UW Medicine.

In Progress...
ACN Request to Join HTML