RURAL HEALTH CLINIC & HOSPITAL CONTACT INFORMATION UPDATE

RURAL HEALTH CENTERS CONTACT INFORMATION UPDATE

In order to improve communication with the Department of Health Office of Rural Health and your clinic or hospital, we need updated contact information including names of main contact person, email addresses and mailing address.

Please include the email addresses of all staff members who wish to be on our mailing list in section #2.

Your responses go to a secure email server within the UDOH OPCRH and will not be shared with an outside entity.

We appreciate you taking the time to update this important information; we look forward to hearing from you.

Question Title

* 1. Please Enter Current Contact Information

Contact Person Name and Job Title

Clinic Main Email Address

Clinic Name

Clinic Mailing Address

Suite # (If Applicable)

City

State

Zip

Main Phone

Name of CEO/Owner/CMO (Please include his/her title)

RURAL HEALTH CLINIC & HOSPITAL CONTACT INFORMATION UPDATE

RURAL HEALTH CENTERS CONTACT INFORMATION UPDATE

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* 1. Please Enter Current Contact Information

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* 2. COUNTY

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* 3. Additional Email Addresses (separate multiple email addresses with a ";")

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* 4. Email of CEO/Owner/CMO

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* 5. Any Additional Contact Information (i.e. Fax #, WEBSITE ADDRESS, additional contact names, etc.)