MEMBERSHIP APPLICATION

To properly establish your organization as a member of America’s Essential Hospitals, please provide us with the key contacts within your organization (by location system/hospital). This will enable us to communicate effectively to your staff and ensure their timely receipt of legislative alerts, conference call and webcast information, and meeting and event notices.

ORGANIZATIONAL INFORMATIONSubmission dateApplicant organizationUHC member?Multihospital system?If yes, list the names of hospitals that should be included in the membership:

Business address (including for overnight delivery) Address 1Address 2City, state, ZIPMain phone Fa

xWebsitePlease attach institution logo or other brand image file (high-resolution vector, if available)

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MEMBERSHIP APPLICATION

Key Officers and Primary Contacts

SYSTEM CHIEF EXECUTIVE OFFICER [CEO1] – Please attach recent photo and updated bioNameTitleHospital nameBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPPhysical address of CEO’s officeAddress 1Address 2City, state, ZIPPhone (direct dial)

Fax

Email WebsiteAssistant’s name Asst.

PhoneAssistant’s email

CHIEF EXECUTIVE OFFICER [CEO] – Please attach a recent photo and an updated bio for CEOs of member hospitals to be listed under your system on our online membership list. We use the bio information for a website spotlight on new member leaders.NameTitleHospital NameBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPPhysical address of CEO’s officeAddress 1Address 2City, state, ZIPPhone (direct dial)

Fax

Email WebsiteAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATION

BILLING CONTACT FOR ASSOCIATION ANNUAL DUES [BLLN]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

CHIEF MEDICAL OFFICER [CMO1]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

CHIEF FINANCIAL OFFICER [CFO]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATION

CHIEF OPERATING OFFICER [COO]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

CHIEF QUALITY OFFICER [CQO1]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

PRIMARY FEDERAL GOVERNMENT RELATIONS OFFICER [GOV]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATION

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MEMBERSHIP APPLICATION

CHIEF NURSING OFFICER [CNO]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

PRIMARY PR/COMMUNICATIONS CONTACT FOR SYSTEM [COM] (if applicable)NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

DIRECTOR OF AMBULATORY CARE OPERATIONS [AMB]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATION

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MEMBERSHIP APPLICATION

EMERGENCY DEPARTMENT DIRECTOR [ED]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

EMERGENCY PREPAREDNESS DIRECTOR [EMP]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

HOSPITAL FOUNDATION DIRECTOR [FND]NameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATION

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MEMBERSHIP APPLICATION

QUALITY DIRECTOR [QUAL] - Your organization may have multiple quality contactsNameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

QUALITY DIRECTOR [QUAL] - Your organization may have multiple quality contactsNameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

QUALITY DIRECTOR [QUAL] - Your organization may have multiple quality contactsNameTitlePhone (direct dial)

Fax

EmailBusiness mailing address (including for overnight delivery)Address 1Address 2City, state, ZIPAssistant’s name Asst.

phoneAssistant’s email

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MEMBERSHIP APPLICATIONPlease return membership application form to:Maeceon Lewis, Senior Membership Coordinatormlewis@essentialhospita ls.org or fax: (202) 585-0575

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