GWTG Rural Health Care Outcomes Accelerator Expedited Enrollment Form
Provide Legal Name of Hospital - No abbreviations please.
Select YES if this hospital is currently enrolled in one or more GWTG modules and this enrollment will be an Add-On.
Select NO if this hospital currently does not participate in any of the GWTG programs.
Select UNKNOWN if you are unsure if this hospital participates in other GWTG programs.
Provide Street Address of the Hospital
Two Letter State Abbreviation
Select one or more modules to enroll in through the Rural Health Care Outcomes Accelerator Program
Provide the first name of the primary contact who should receive the contracting information.
Provide the last name of the primary contact who should receive the contracting information.
Provide the email address of the primary contact who should receive the contracting information.
Provide the title of the primary contact who should receive the contracting information.
Select YES if the primary contact named above will also be the signatory of the contract.
Select NO if the primary contact named above will not be the signatory of the contract.
As the contracting process is in progress, a meeting to provide a demonstration of GWTG can be scheduled. Select YES if you'd like to have a demo meeting scheduled. Select NO otherwise.
Provide any additional notes or questions as it relates to the enrollment and contracting process.