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Encore Physicians Program

Use this form to apply to the Encore Physicians Program. If you wish, you may save a partially-completed form and finish it later. When you are satisfied with all your responses, click the "submit" button at the bottom. When you click "submit" you will be shown a confirmation page where you may review and click "confirm" to finalize your responses. You will also have a "print" option at the bottom of the page. Once you have confirmed the form, you will no longer be able to edit it, and your information will be added to our database for review and consideration. Thank you for your interest in the Encore Physicians Program!

Contact Information

Location Preference

Please complete the questions in the space provided (250 words maximum)

Thank you for your interest! If you have any questions about this form, please contact us Tom at tburns@cogenerate.org. (Please note that saving a form is not the same as submitting it. Your information will only be submitted for consideration once you hit the Submit button below and Confirm on the next page.)

Data Privacy Statement

When you submit data as part of the Encore Physicians Program application and evaluation processes, you agree to the terms outlined in our data privacy statement. Please remember that while we are very committed to respecting applicant privacy, the nature of the application and matching process requires that we share information you provide us with other organizations. The data privacy statement helps explain what you can expect with respect to our treatment of your information.