Fax Cover Sheet to Determine Provider Status - Promotion

Appendix B – Fax Cover Sheet to Determine Provider Status

Form Approved

OMB No. 0923-XXXX Exp. Date xx/xx/20xx

[ON PROJECT FAX COVERSHEET]

Promotion of the National ALS Registry to Non-referral Centers

Fax

	To: Dr. XXXXX		From:
	Organization:		Organization: McKing Consulting Corporation
	Phone:		Phone:
	Fax:		Secure, Toll Free Fax:
	Date:		Number of Pages:
Comments:

The Agency for Toxic Substances and Disease Registry (ATSDR), a public health agency within the US Department of Health and Human Services, awarded McKing Consulting Corporation (McKing) a contract to promote the National ALS Registry (Registry) to non-referral center neurology practices in your state. The objectives of this pilot project are to conduct educational and promotional outreach activities to inform neurologists and their staff about the Registry, to encourage them to inform their patients about the Registry, and to increase Registry self-enrollment among persons with ALS.

Members of our project have attempted to reach your office to determine if you are currently diagnosing and/or caring for any patient with ALS. Please indicate on this letter if you currently diagnose and/or treating ALS patients and fax it back to (855) 598-7485 (toll free).

I currently diagnose and/or care for ALS patients.

I have diagnosed and/or cared for ALS patients in the past, but do not currently do so.

I do not diagnose and/or care for ALS patients.

If you have questions about this project, please contact Heather Jordan at (609) 613-6930/[email protected] or Lindsay Rechtman (404) 683-4394/[email protected].

Thank you in advance for your support of National ALS Registry Promotion Project.

Sincerely,

Wendy E. Kaye, PhD

Project Director, National ALS Registry Promotion Project