AHRQ Safety Program for Telemedicine: Improving Antibiotic Use | Enrollment Form

Thank you for your interest in the AHRQ Safety Program for Telemedicine: Improving Antibiotic Use. Please provide all information requested in the online enrollment form. You will need to complete the enrollment form in one sitting. You will not be able to save the form and continue later.

If you represent a health system or a consortium of healthcare practices and would like assistance to enroll multiple practices, please contact us at safetyprogram4telemedicine@norc.org.

The enrollment form should take approximately 5-10 minutes to complete. You will be asked to share:

Your practice type
Which regions your practice serves
Where your practice is located
Your practice’s affiliations to any health systems or other entities
Number of clinicians you are enrolling
Two points of contact for your practice
Your practice’s EHR vendor and experience with the EHR

If you have any questions or technical difficulties, contact the program team at safetyprogram4telemedicine@norc.org.

After completing the online enrollment form, click on the Submit button; you will receive a confirmation message when your form is successfully submitted. If you would like to complete the enrollment form for multiple practices, click the Enroll Another Practice button at the conclusion of the form. After submitting the form, you will receive an email from safetyprogram4telemedicine@norc.org within 5 business days of submission regarding next steps.