NAACOS Members / ACO Membership Application

Organization Name*

Type of Organization*

Applying to become a CMS ACO in the next year

Medicaid ACO

Multiple CMS ACOs under one organization

REACH ACO

Single MSSP ACO

Value-Based Care Organization (does not have MSSP or REACH contract with CMS)

Value Based Care Provider Group

Address Line 1*

Address Line 2

City*

State*

Zip/Postal*

Country*

Website*

Primary Contact Name*

E-Mail*

Total number of beneficiaries

Total number of providers (physicians, NPs, PA, CNS)