Participation Agreement

Thank you for expressing your interest in Jericho REACH and giving us permission to provide that information to CMS.

In order for you to participate in 2023, you will need to sign and return a formal Participation Agreement by December 31, 2022. You can review that document below.

NOTE: If you need to add additional interested clinicians from your practice by August 6th, use this link. After submitting, you will be returned here.

Confidentiality Agreement

By checking this box I agree that the Participation Agreement I will receive as a result of sending this form is confidential information of Jericho REACH. I further agree that Jericho REACH retains all rights to it; that I will keep it in strict confidence using at least the same level of care, but not less than reasonable care, as I do my own confidential information; that I will disclose it only on a need-to-know basis only for evaluation of participation in Jericho REACH and not disclose it for any other purpose; and that I will inform Jericho REACH if there is any unauthorized use or disclosure.

Name

First Name

Last Name

* Required

Should you decide to join Jericho REACH after reviewing the PA, please print and sign the document, scan it, and return it as an attachment to jericho@jerichoreach.com with the subject title: “Signed PA”.