NCHA Member Application - Hospitals/Health Systems
FACILITY INFORMATION
Facility Name
*
Primary Service
*
General Acute Care
Long Term Acute Care
Psychiatric Services
Rehabilitation Hospital
Specialty Hospital
Veterans Hospital
Type
*
Not for Profit
For Profit
Address line 1
*
Address line 2
City
*
State
*
Zip
*
Web Address
*
LEADERSHIP
CEO name
*
CEO Executive Assistant
*
Executive Assistant phone
*
Executive Assistant Email
*
APPLICANT INFORMATION
Your name
*
Title
Your email
*
Your phone
*
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