Exit ATP Membership Inquiry Question Title * 1. Address Your Name Organization Name Mailing Address City/Town State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Your Title Your Email Address Your Phone Number Question Title * 2. Type of Organization Private Practice State Office of Rural Health Hospital Critical Access Hospital (CAH) Clinic County Health Department University Health Department FQHC Community Health Clinic AHEC Vendor Other (please specify) Question Title * 3. What type of ATP membership are you interested in finding out more about? (Check all that apply.) Full Membership Standard Membership Educational Membership Question Title * 4. What type of assistance are you seeking from ATP? (Check all that apply.) Continuing Medical Education Telemedicine training Facility consulting Network engineering support Grant review Managed videoconferencing Technical consulting Program assessment / evaluation Other (please specify) Question Title * 5. Do you currently have any telemedicine/telehealth programs in place? Yes No If yes, please describe Question Title * 6. Are you looking at starting or expanding telemedicine/telehealth programs? Yes No If yes, please describe Question Title * 7. Best way to contact you Email Phone Done