Practice Recognition Award Program

Your Name *

Your Institution *

Practice that is being recognized * The name of the practice exactly as it should appear on the certificate and letter of congratulations.

Full Name of Person at practice to whom letter should be addressed * The full name of person at practice exactly as it should be printed on the letter of congratulations. Example: John M. Smith, PhD

Last Name of Person at Practice The last name of the person at practice exactly as it should be printed in the salutation of the letter. Example: Smith

Person at practice’s street address *

Person at practice’s city, state, and zip *

Title for letter salutation *

Check each box to indicate practice you’re nominating has met the criteria:

Demonstrates a culture of support for the education of primary care providers. Leadership communicates that participation in education benefits the practice and patient care. *

Welcomes learners and allows them to participate meaningfully as members of the health care team in roles appropriate to their level of training. *

Has precepted a reasonable number of students (based on size) for at least the past two years. *

Has implemented patient-centered practices and processes. *

Allows students to write patient encounter notes in the EHR. *

Submit