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PROJECT ACCESS PHYSICIAN COMMITMENT FORM

Name: *
Specialty: *
Practice Group Name: *
Address:
Phone:
Fax:
Email: *
Hospital Privileges:

YES! I'll do my part to make the Jefferson County Area Project Access a success.

Here's my 12-month pledge beginning:

I will:
Accept () Specialty Care referrals - please consider 12 (insert number)
Accept () Primary Care referrals - please consider 6 (insert number)
* Please note that Project Access is not designed to provide long term assistance and patients are required to requalify every six months to remain in the Project Access Program.

Please contact me, I have questions about the Jefferson County Area Project Access.
I am not interested in volunteering for Project Access at this time, but keep me posted as the program develops.

* Required Field


download printable form

If you have any questions, please contact:

~ Irby Ferguson, Director of Project Access at (205) 271-6820
~ Martha Wise, Executive Director of Jefferson County Medical Society at 205-933-8601

If downloading the printable form, please return to Project Access at the Medical Society office: