Provider Resources Directory for <CCC program name> How to Use: Replicate the table of information below for each provider participating in or supporting the CCC program. Add additional information as appropriate for the program. Consider using a spreadsheet or formatted database for easy access, sorting and reporting of the information. <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> Mailing Address (if different) <Phone number> <Fax number) <website address> (if any) Process to <Forms or referral requirements> Other Requirements Obtain Services <Lead time> Additional <Expectations for data sharing, service follow up, reports, issue management, etc.> Information <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> Mailing Address (if different) <Phone number> <Fax number) <website address> Process to <Forms or referral requirements> Other Requirements (if any) Obtain Services <Lead time> Additional <Expectations for data sharing, service follow up, reports, issue management, etc.> Information <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> Mailing Address (if different) <Phone number> <Fax number) <website address> Process to Other Requirements (if any) <Forms or referral requirements> Obtain Services <Lead time> Additional <Expectations for data sharing, service follow up, reports, issue management, etc.> Information
Provider Resources Directory for <CCC program name> How to Use: Replicate the table of information below for each provider participating in or supporting the CCC program. Add additional information as appropriate for the program. Consider using a spreadsheet or formatted database for easy access, sorting and reporting of the information. <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> <Phone number> <Fax number) <website address> Mailing Address (if different) Process to Obtain Services <Forms or referral requirements> <Lead time> Other Requirements (if any) Additional Information <Expectations for data sharing, service follow up, reports, issue management, etc.> <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> <Phone number> <Fax number) <website address> Mailing Address (if different) Process to Obtain Services <Forms or referral requirements> <Lead time> Other Requirements (if any) Additional Information <Expectations for data sharing, service follow up, reports, issue management, etc.> <Name of Provider> Specialty <Name of specialty(ies)> Organization <Primary organization> Location <Street, City, Zip code> <Phone number> <Fax number) <website address> Mailing Address (if different) Process to Obtain Services <Forms or referral requirements> <Lead time> Other Requirements (if any) Additional Information <Expectations for data sharing, service follow up, reports, issue management, etc.>
4-Provider-Resource-Directory-Template.docx