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ICAHN RHTP Technology Innovation Initiative - Hospital Information and Contacts

This form is meant to gather basic hospital and contact information for assessment activities in the Technology Innovation initiative being led by the Illinois Critical Access Hospital Network (ICAHN) for Illinois RHTP. Hospitals eligible for Technology Innovation initiative funding can be found on the ICAHN website, here. Participation in assessment activities is required for hospitals to apply for Technology Innovation project funding. Submit only one form per hospital by Wednesday, October 28, 2026 at 5 PM Central Time.

This funding opportunity is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $193,418,216.21, with 100 percent funded by CMS/HHS and awarded through the Illinois Department of Healthcare and Family Services.
1.Hospital Name(Required.)
2.Hospital Town/City(Required.)
3.Hospital Zip Code(Required.)
4.Hospital Designation(Required.)
5.Hospital's Licensed Bed Count(Required.)
6.Total FTEs Employed by Hospital (current approximate #)(Required.)
7.Hospital's Primary Electronic Health Record (EHR) Vendor & Version(Required.)
8.List Any Other EHRs Used by Hospital (if applicable)
9.Which best describes the hospital's primary information technology (IT) support model?(Required.)
10.How many full-time equivalent staff members are dedicated to providing IT support for the hospital? (Include employees whose primary responsibilities are IT-related, whether they work exclusively for the hospital or support multiple facilities within the organization. Do not include external IT vendors or managed service provider staff.)(Required.)