{Date} Primary Care Initiative Program Management Office Attention: Transition Coordinator 10411 125 Street Edmonton, AB T5N

4A2 Dear Committee Members: This letter, jointly developed by local physicians and Alberta Health Services (AHS) representatives, demonstrates our commitment to work together on developing a Primary Care Network (PCN). Our proposed Primary Care Network is: Name of PCN (can be changed later): Alberta Health Services Zone: Geographic area and population centres to be covered by the PCN: {PCN Name} {Alberta Health Services Zone} {Geographic Area} {#} {#} {#}

Total number of physicians in PCNs area ({estimate or actual}): Total number of participating physicians: (who are all signing this letter): Number of clinics/physician offices which the signing physicians represent:

Our PCN is committed to the five Primary Care Initiative provincial objectives:

Increase the proportion of residents with ready access to primary care Provide coordinated 24-hour, 7-day-per-week management of access to appropriate primary care services Increase the emphasis on health promotion, disease and injury prevention, care of the medically complex patient, and care of patients with chronic disease Improve coordination and integration with other health care services including secondary, tertiary and long-term care, through specialty care linkages to primary care Facilitate the greater use of multidisciplinary teams to provide comprehensive primary care

During the business planning process, we intend to develop:

A project plan, and submit it as specified, to access project funding to support service planning. A description of proposed programming for our area, written up in a service delivery outline, and submit this plan to access further project funding. A business plan that meets PCIC requirements and which will be submitted for review as an application for ongoing PCN funding.

Version 4.0 (December 2010)

In deciding to form a PCN, and in developing this letter, we have identified the following issues and challenges in our area: Service Responsibility Socio-economic factors, unique conditions, challenges, and other issues that make this service responsibility an issue for our PCN:

1. Basic ambulatory care and follow-up 2. Care of complex problems and follow-up 3. Psychological counselling 4. Screening/chronic disease prevention 5. Family planning and pregnancy counselling 6. 7. 8. 9. 10. patients 11. 12. Well-child care Obstetrical care Palliative care Geriatric care Care of chronically ill Minor surgery Minor emergency care

13. Primary in-patient care including hospitals and long-term care institutions 14. 15. Rehabilitative care Population health

16. Information Management 17. 24-hour, 7-day perweek management of access to appropriate primary care services 18. Access to laboratory and diagnostic imaging 19. Coordination with Regional Services (Home Care, Emergency Room Service, LongTerm Care, Secondary Care, and Public Health) 20. Acceptance into the Primary Care Networks patient population and provision of the service responsibilities to an equitable and agreed upon allocation of unattached patients.
Letter of Intent

We understand it is our responsibility to notify as soon as possible the PCI Program Office of the name and contact information. We expect to confirm our priorities for development during the business planning process, but meanwhile, our initial thoughts are that the PCN will focus on{overview of initial priorities}. We understand it is our responsibility to notify the PCI Program office as soon as possible with the contact information once we employ a Project Manager to help us meet our commitments and generate these required documents. We understand that this is a collaborative process in which the AHS and physicians make consensus-based decisions about the proposed PCN. We estimate that we will complete our business plan in about {#} months. Please direct any further communication about our PCN to: Name: Title: Organization: Mailing Address: Email: Phone: Signature: This letter is also our request for business planning funding to develop a detailed project plan and initiate business plan development. The business planning funding cheque should be made payable to {Payee} and sent to the attention of: {Name} Title: Organization: Mailing Address: Email: Phone: {Title} {Organization} {Mailing Address} {E-mail} {Phone} Fax: {Fax} {Name} {Title} {Organization} {Mailing Address} {E-mail} {Phone} Fax: {Fax}

Any additional funding required to complete business planning will be detailed and justified in our project plan.

Letter of Intent

With our signatures below, we verify the contents of this letter and agree that our PCN will be developed in accordance with specified requirements. AuthoriPhysician Lead zation Name(s Dr. {Name(s)} ): Title: Lead Mailing {Address} Address : {Email} Email: Phone(s {(xxx) xxx-xxx} ): {(xxx) xxx-xxx} Fax: Signatu re: With our signatures below, we verify the contents of this letter and agree that our PCN will be developed in accordance with specified requirements. Name and Clinic of Participating Physicians {Name} {Clinic} {Name} {Clinic} {Name} {Clinic} {Name} {Clinic} {Name} {Clinic} {Name} {Clinic} Signature Date Local AHS Lead {Name} {Title} {Address} AHS Zone V.P. {Name} {Title} {Address}

{Email} {(xxx) xxx-xxx} {(xxx) xxx-xxx}

{Email} {(xxx) xxx-xxx} {(xxx) xxx-xxx}

Letter of Intent