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Institutional Member Application

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Main Office
801 Penn. Ave. NW
Suite 245
Washington, DC
20004-2604
[T] 202 624 1500

Administrative Office
1405 N Pierce St, Suite 311
Little Rock, AR 72207
[T] 501 661 9555

Fields mark with * are required fields.
*

Name
*

Company
*

Address Line 1

Address Line 2
*

City
*

State
*

Zip
*

Phone #

Fax #
*

E-mail
*

Number of facilities owned

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Date Opened
*

Year First Licensed

*

Is Hospital General or Specialty? If Specialty, what kind?

  General
 Specialty
*

Name of Chief Executive Officer
*

Name of Chief Financial Officer

*

Hospital Owned/leased or managed – By what company?

  Owned/leased
 Managed
*

JCAHO 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.