Voices of Detroit Initiative
Membership Application

Organization Name

Address

Telephone

Fax

Type of Provider Organization
(please check all that apply)

Does the Organization have mechanisms
for engaging the community in decision-making?

Yes
No

Does the Organization have a Strategic
Plan for sustainable funding?

Yes
No

Does the Organization have formalized
arrangements to assure continuum of
care (inpatient, hospital, and specialty care)?

Yes
No

Does the Organization provide access
to care or arrange for care access one-two
evenings per week or have weekend hours?

Yes
No

Do you agree to participate in VODI
data tracking collection activities?

Yes
No

Do you agree to participation in VODI enrollment
procedures for low-income, uninsured persons?

Yes
No

Do you agree to participate in appropriate
Quality Assurance practices?

Yes
No

Do you agree to provide/cover the minimum
set of core services as defined by VODI?

Yes
No

Your email address

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