Hospital and System Information

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* 1. Hospital Name(s):

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* 2. Location of Hospital(s) (County)

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* 3. Hospital Medicare Provider Number(s)/CCN(s)

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* 4. Hospital Ownership Category

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* 5. Hospital Contact (Name):

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* 6. Hospital Contact (Email Address):

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* 7. Hospital Contact (Phone Number):

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* 8. How many hospitals are you responding on behalf of? 

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