Highland Rim Health Care Coalition Membership Registration

Membership Registration

Question Title

* 1. Please enter your entity/facility contact information.

Company

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Question Title

* 2. In which county is your entity/facility located?

Cheatham

Davidson

Dickson

Houston

Humphreys

Montgomery

Robertson

Rutherford

Stewart

Sumner

Williamson

Wilson

Other (please specify)

Question Title

* 3. Please enter the primary contact person.

Name

Email Address

Phone Number

Question Title

* 4. Please enter an alternate contact person.

Name

Email Address

Phone Number

Question Title

* 5. Please list a corporate contact (if applicable):

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 6. Please choose your entity type:

Hospital

Critical Access Hospitals (CAH)

Outpatient Health Care Delivery Centers (Acute Surgery Center, Outpatient Rehabilitation, etc)

End-Stage Renal Disease (ESRD) Facilities - Dialysis

Hospice

Psychiatric Residential Treatment Facilities (PRTF)

Long-Term Care (LTC) Facilities (skilled nursing, assisted living, homes for the aged, inpatient rehabilitation)

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

Home Health Agencies (HHA)

Primary care providers, including pediatric and women's health care providers

Behavioral health services and organizations

Organ Procurement Organizations (OPO) and Transplant Centers

Blood Banks and Laboratories

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

Schools and Universities, including academic medical centers

Emergency Medical Services (EMS)

Emergency Management Agencies (EMA)

Local public safety agencies

Support Service Providers (Hearing and Vision impaired)

Public or Private Payers

Specialty patient referral centers

Infrastructure companies

Jurisdictional partners, including cities, counties, and tribes

Non-governmental organizations (RedCross, American Cancer Society, Americares, American Heart Association, etc)

Public Health

Other (please specify)

Question Title

* 7. Each entity is required to be a member of at least one subcommittee. You may choose as many as you like if you have personnel you would like to represent your facility. Please choose the subcommittee(s) you would like to join:

Non-Hospital: Works directly with CMS17 provider types to encourage information and support for the coalition

Response: Provides gap analysis from Plans and Annex subcommittee to Training and Exercise subcommittee (Response agencies highly recommended)

Information and Technology: Handles all membership, website, and social media for the coalition

Training and Exercise: Schedules all trainings and holds exercises for the coalition

Plans and Annex: Helps develop all plans and annexes required by Assistant secretary of Preparedness (ASPR)