MAPP-Net Enrollee Application

Title

First Name

Last Name

Are you enrolling to access services for:

Name of your primary practice or clinic:

Public Email address of practice or clinic (This address MAY BE PUBLISHED):

Email address (Most direct address to reach you. This address WILL NOT BE PUBLISHED):

Mailing Address, Street (or PO Box) and City:

Zip Code of primary practice or clinic location:

Which best describes your role?

Individual healthcare provider (e.g., primary care or specialist)
Individual behavioral health provider (e.g., counseling professional)
Representative of practice or clinic (e.g., clinic or practice manager, care coordinator)