Saturday, February 04, 2012
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Institutional Member Application

Fields marked with * are required fields.
* Name
* Company
* Address Line 1
  Address Line 2
* City
* State
* Zip
* Phone #
  Fax #
* E-mail
* Number of facilities owned
* Date Opened
* Year First Licensed
* Is Hospital General or Specialty
  -If Specialty, what kind?
* Name of Chief Executive Officer
* Name of Chief Financial Officer
* Hospital Owned/Leased or managed
  -By what company?
* TJC Accreditation
* Is Hospital Certified to participate in Medicare? Date of Certification
* Is Hospital Certified to participate in Medicaid? Date of Certification
If hospital has operated under another name and ownership classification, give name and ownership

Institutional membership will entitle six hospital employees to receive all Federation publications. Please identify below those to be placed on the FAH members mailing list.
Name Title
1.
2.
3.
4.
5.
6.
Federation of American Hospitals • 750 9th Street, NW, Suite 600 • Washington, DC 20001 • 202.624.1500
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