CPP Application

    North Carolina Medical Society Foundation Community Practitioner Program
    (To be completed by the applicant)

    I.Personal Information

    Have you ever been denied a license or have a license revoked or suspended by any professional licensing board?

    Have you ever been warned, censured, disciplined, had admissions monitored, had privileges limited or denied by any licensed hospital, nursing home, clinic, or managed care organization?

    II.Practice Information

    2. Is this a federal, state, academic or hospital run practice?

    III.Practice Setting's Willingness to Improve Access for the Underserved

    1.Accept Medicaid?
    2.Accept Medicare?
    3.Indigent Care?

    IV.Technology and Quality

    1.Does the practice have a certified Electronic Health Record or do you plan to acquire one?

    2.If the practice has an EHR, are they working toward achieving Meaningful Use?

    3.Does the practice have a strategic plan to obtain Patient Centered Medical Home Status?

    V.Evidence of Practice Viability

    2.Is there a practice/business manager?

    VI.Evidence That Practitioner and Family Will Fit Into the Community

    1.Will practitioner live in the community?

    2.Will practitioner's spouse accept and become part of the community?

    3.Will children attend local schools?

    4.Will practitioner become a part of the community ?

    VII.Availability of other Funds for Assistance

    2.Do owners or partners have funds to assist applicant's educational loan repayment?

    3.Does local hospital have funds to assist applicant's educational loan repayment?

    4.Are there income sources other than patient income?

    VIII.Educational Loan Information

    (Undergraduate or living expense loans to not qualify.)

    Have you applied for state or federal education grants?

    Are you receiving state or federal education grants?

    *Please note that the Physicians and PA's employed by the facility you are currently working in will need to become members of the North Carolina Medical Society for you to be considered for a loan through the Community Practitioner Program.