We apologize, but due to unforseen circumstances, our online form is currently offline. We expect to have it operational again shortly.
In the mean time, please contact us via email at firstname.lastname@example.org with the following information:
- Hospital information
- Hospital Name
- Address 1/2
- City, State, ZIP
- Medicare ID
- Number of Beds
- Is your hospital a teaching hospital?
- Is your hospital a member of a system?
- Is your hospital publicly owned, not for profit, or for profit?
- Contact Person
- Contact Name
- Contact Email (if different than the sending email address)
- Contact Number
- Date you would like to begin HLQAT