SW Washington Healthcare Alliance Membership Contact Form

SW Washington Healthcare Alliance

Membership Contact Form

Please complete the following contact form for your organization, only one form per facility/organization. Click submit when complete and the form will automatically share with the Healthcare Alliance.

Questions? Contact Marisa Hutcheson at 360.946.6902 or marisa.hutcheson@clark.wa.gov.

Organization Information

Organization Name

County

County your organization is located in

Select or enter value

Organization Address

Organization City

Organization State

Organization Zip Code

Primary Contact Information

Primary Healthcare Alliance representative information

Primary Contact First Name

Primary Contact Last Name

Primary Contact Job Title

Primary Contact Email

Primary Contact Phone

Phone

Ext.

Alternate Contact Information

Designated Alternate Healthcare Alliance representative information

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Job Title

Alternate Contact Email

Alternate Contact Phone

Phone

Alternate Ext.

24/7 Contact Information

Please provide contact information for a 24/7 contact from your organization. This can be a general number or email address for a House Supervisor, ED Charge Nurse, Administrator On-Call, Call Center, etc.

24/7 Contact Job Title

24/7 Contact Email

24/7 Contact Phone

Phone

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