To properly establish your organization as a member of America’s Essential Hospitals, please provide us with the key contacts within your organization (by location system/hospital). This will enable us to communicate effectively to your staff and ensure their timely receipt of legislative alerts, conference call and webcast information, and meeting and event notices.

Organizational Information
Submission date
Applicant organization
UHC member?
Multihospital system?
If yes, list the names of hospitals that should be included in the membership:
Business address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Main phone / Fax
Website
Please attach institution logo or other brand image file (high-resolution vector, if available)

Key Officers and Primary Contacts

System Chief Executive Officer [CEO1] – Please attach a recent photo and an updated bio
Name
Title
Hospital name
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Physical address of CEO’s office
Address 1
Address 2
City, state, ZIP
Phone (direct dial) / Fax
Email / Website
Assistant’s name / Asst. Phone
Assistant’s email
Chief Executive Officer [CEO] – Please attach a recent photo and an updated bio for CEOs of member hospitals to be listed under your system on our online membership list. We use the bio information for a website spotlight on new member leaders.
Name
Title
Hospital Name
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Physical address of CEO’s office
Address 1
Address 2
City, state, ZIP
Phone (direct dial) / Fax
Email / Website
Assistant’s name / Asst. phone
Assistant’s email
Billing Contact for Association Annual Dues [BLLN]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Chief Medical Officer [CMO1]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Chief Financial Officer [CFO]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Chief Operating Officer [COO]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Chief Quality Officer [CQO1]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Primary Federal Government Relations Officer [GOV]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Chief Nursing Officer [CNO]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
PRIMARY PUBLIC RELATIONS/COMMUNICATIONS CONTACT FOR SYSTEM [COM] – if applicable
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Director of Ambulatory Care Operations [AMB]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Emergency Department Director [ED]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Emergency Preparedness Director [EMP]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Hospital Foundation Director [FND]
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Quality Director [QUAL] - Your organization may have multiple quality contacts
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Quality Director [QUAL] - Your organization may have multiple quality contacts
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email
Quality Director [QUAL] - Your organization may have multiple quality contacts
Name
Title
Phone (direct dial) / Fax
Email
Business mailing address (including for overnight delivery)
Address 1
Address 2
City, state, ZIP
Assistant’s name / Asst. phone
Assistant’s email

Please return membership application form to:

Maeceon Lewis, Senior Membership Coordinator

or fax: (202) 585-0575

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