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Appendix A: Participant Application Guidance and Questions

This document is not the application to be filled out by the applicant; this is a list of the questions that may be found in the online application portal and is provided for reference only. The online application portal can be accessed via a link on the GUIDE Model website: https://innovation.cms.gov/innovationmodels/guide. All GUIDE applications must be submitted through the online application portal by 11:59 pm Eastern Daylight Time on January 30, 2024.

CMS may seek additional information from applicants to the GUIDE Model after the application period closes. Not all applicants are guaranteed participation in the GUIDE Model. In selecting participants, CMS will consider factors critical to ensuring a robust evaluation of the GUIDE Model. CMS may also deny individual clinicians or any other individual or entity participation in the GUIDE Model based on the results of a program integrity review.

CMS will safeguard the information provided in accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a). For more information, please see the CMS Privacy Policy at https://www.cms.gov/ privacy.

For questions regarding the GUIDE Model or the GUIDE application process, email [email protected].

Complete Profile (Section 1)

Organization Information (Tab 1)

1. GUIDE Model Applicant Information

• Legal Business Name:
• Doing Business As (DBA):
• Organization TIN/EIN:
• Street Address:
• City:
• State:
• ZIP Code:
• Website, if applicable:

1. How would you define your organization (Check all that apply or check N/A if your organization is not on this list):

1. Did the applicant submit a Letter of Interest (LOI) for the GUIDE Model? (Optional) (A Letter of Interest is not a requirement to apply for the Model, this information will only be used for tracking purposes)