Interested In Joining

Phone

This field is for validation purposes and should be left unchanged.

THIS IS NOT AN APPLICATION FOR MEMBERSHIP

Please use this form to indicate your group’s interest in applying to Princeton PO. If your group is determined to be a good fit for the organization, we will follow up with instructions for your providers to apply for Princeton PO Membership.

Preparer Information

Group/Practice Name(Required)

Your Name(Required)

Salutation First Last

Your Email(Required)

Your Phone Number(Required)

What is you role in the practice?(Required)

Owner/ Partner

Employed Physician

Office Manager

Other

Group Information

Does your group have a website?(Required)

Yes

Group Website URL(Required)

Primary Group Specialty(Required)

Is this a multi-specialty group?(Required)

Yes

Additional Group Specialties(Required)

Use the plus sign to add additional specialties

How many office locations does the practice have?(Required)

Please list the city and state where offices are located.(Required)

Are any of you office locations considered to be an urgicenter?(Required)

Yes

Do all providers in the practice work on the same tax ID number?(Required)

Yes

No, the practice uses two or more TINs

Does the practice use an EMR system? If so, please provide the name of the system.(Required)

(If no, please enter N/A)

Does the practice currently participate in a quality initiative? If so, please provide the name of the program.(Required)

(If no, please enter N/A)

Does the practice currently participate with another physicians' organization, hospital organization, PHO, or IPA? If so, please provide the name of the organization.(Required)

(If no, please enter N/A)

Provider Information

How many physicians work in the practice?(Required)

Please enter a number greater than or equal to 0.

How many mid-level practitioners work in the practice?(Required)

Please enter a number greater than or equal to 0.

Are all providers in the practice board certified?(Required)

Yes

No, but one or more providers are in the process of becoming board certified.

No, one or more providers are NOT board certified and do not plan to become board certified.

Do ALL providers (physicians and midlevel) in the practice currently have privileges at one or more NJ hospital?(Required)

Yes, all providers have active providers at at least one NJ hospital

Only some group providers have active providers at at least one NJ hospital

No, no providers have privileges at any NJ hospital

Please list all NJ hospitals at which group providers have privileges.(Required)

Provider Information

Were you referred or invited to Princeton PO by someone? If so, by whom?(Required)

(If no, please enter N/A)

Why do you want to join Princeton PO?(Required)

What do you believe your practice will bring to Princeton PO? What makes your group special?(Required)

Have any providers in your practice been published in any medical journals, articles, or other publications?

Does your practice participate in any community service or mission work??

Review Your Responses

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The Medical Center of Princeton Physicians' Organization

Membership Interest Form

THIS IS NOT AN APPLICATION FOR MEMBERSHIP

Preparer Information

Group Information

Provider Information

Provider Information

Review Your Responses

The Princeton Physicians’ Organization

The Medical Center of Princeton Physicians' Organization

The Medical Center of Princeton Physicians' Organization

Membership Interest Form

**THIS IS NOT AN APPLICATION FOR MEMBERSHIP**

Preparer Information

Group Information

Provider Information

Provider Information

Review Your Responses

The Princeton Physicians’ Organization

THIS IS NOT AN APPLICATION FOR MEMBERSHIP