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) Done