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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.

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Clinic Information

Enter hours by day of the week (M-F 8-6, etc.)

Contact Information

Provider Information

Enter all provider names you want to inform us about
Enter the HTTP address of your clinic site
Enter all the specialties you wish to inform us about
Enter all the hospital affiliations your clinic has

Clinic's Electronic Health Record (EHR), if applicable

Enter the EHR your clinic has

Product(s) Open to New Provider Groups

At this time, the only product open to new provider groups is HCA (PEBB/SEBB).
If interested in the HCA (PEBB/SEBB) product, does the clinic have a UMP contract?