1. Registration Information

Thank you for your interest in The Joint Commission's Disease-Specific Care Certification program. Please complete this brief form to help us better serve you. Following completion of this form, you will gain access to a variety of tools to help you better understand and prepare for certification with The Joint Commission. Everything you need is here at your fingertips and in one convenient place!

For questions related to this form, e-mail deickemeyer@jointcommission.org

* 1. First Name

* 2. Last Name

* 3. Credentials

* 4. Title/Position

* 5. Company Name

* 6. Street Address

* 7. City

* 9. Zip Code

* 10. Telephone Number

* 11. Fax Number

* 12. E-mail Address

* 13. My organization is (please check all that apply):

* 14. We are interested in disease-specific care certification for the following programs: (check all that apply)

* 15. When would you be interested in pursuing certification with The Joint Commission?