North Sound ACH 7/18/2018
North Sound ACH 7/18/2018
7/25/2018 9:03:49 AM
7/25/2018 9:03:43 AM
North Sound ACH
Council Approval Date
Department Project Manager
Subject / Project Title
Medication Transformation Portal Terms of Svc
6 Years Then Destroy
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
All rights reserved.
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View plain text
CITY <br /> NORTH SOUND ACH 2018 PARTNER APPLICATION: Part 1 <br /> Please provide the following information in the form below.Additional pages can be <br /> used if you need more space. <br /> Organization Name: City of Everett EIN/Tax ID:91-600-1248 <br /> Organization Name Listed on W9:City of Everett <br /> Physical Address: 2930 Wetmore Ave., Everett, WA 98201 <br /> Mailing Address,If different: <br /> CEO/ED Name: Mayor Cassie Franklin <br /> CEO/ED Email: email@example.com Phone: 425-257-7119 <br /> _....._.._..,.-- <br /> Application Completed by: • .... ... ..... ..... ... . <br /> Name: Hil Kaman Title: Public Health and Safety Director <br /> Email: firstname.lastname@example.org Phone: 425-257-8762 <br /> Counties Served by Your Organization:(check all that apply): <br /> ❑ Island ESan Juan ['Snohomish ['Skagit ❑Whatcom <br /> • <br /> Select sectors that best describes your organization:(You can select more than one) <br /> ❑Behavioral Health :Primary Care ❑Hospital/Health System <br /> ❑ Education ❑Employment ['Emergency Medical Services <br /> ❑Food/Nutrition Housing ❑Public Health <br /> ❑Social Services [—]✓ Transportation 0 Tribal <br /> ❑✓ Other(please identify) Police Embedded Social Workers, High-utilizer coordination (CHART), Mu <br /> Select the best descriptive type for your organization: (you can select more than one) <br /> ❑ Medical Provider(Primary Care,Specialty,Hospital,or Emergency Department) <br /> ❑ Behavioral Health Provider(Substance Use Treatment and Mental Health Treatment) <br /> ❑ Tribal Health Clinic <br /> ❑ Tribal Behavioral Health <br /> ✓❑ Fire&Rescue with EMS <br /> ❑✓ Law Enforcement <br /> ❑ Education Organization <br /> ❑ Community Action Agency/Program <br /> ❑ County Public Health, Health or Human Services <br /> ❑ Area Agency on Aging <br /> ✓❑ Other Agencies(not otherwise described).Probration, Transit Operator, Human Services Funder <br /> North Sound ACH May 2018 Call for Partners Application <br />
The URL can be used to link to this page
Your browser does not support the video tag.