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WHA Hospitals and Large Healthcare Organizations Membership Application

Please fill out the application below or download the application here, fill it out, and return it to angelina.salazar@wha1.org.

WHA Hospitals and Large Healthcare Organizations Membership Application

Facility Information

Critical Access Hospital Designation

Chief Executive Officer

Name
Name
First
Last
Executive Assistant Name
Executive Assistant Name
First
Last

Chief Financial Officer Contact

Name
Name
First
Last
Executive Assistant Name
Executive Assistant Name
First
Last

Designated Contact with WHA (if different from CEO)

Is designated contact different from CEO?
Name
Name
First
Last
Executive Assistant Name
Executive Assistant Name
First
Last

Chief Medical Officer Contact

Name
Name
First
Last

Chief Nursing Officer Contact

Name
Name
First
Last

Communications & Marketing Contact

Name
Name
First
Last

Compliance Contact

Name
Name
First
Last

Emergency Department Contact

Name
Name
First
Last

Health Information Management/Medical Records Contact

Name
Name
First
Last

Human Resources Contact

Name
Name
First
Last

Infection Control Director Contact

Name
Name
First
Last

Information Technology Contact

Name
Name
First
Last

Laboratory Contact

Name
Name
First
Last

Materials Management Contact

Name
Name
First
Last

Practice Administrator Contact

Name
Name
First
Last

Quality Improvement / Risk Management Contact

Name
Name
First
Last

Radiology Contact

Name
Name
First
Last

Rehabilitation Contact

Name
Name
First
Last

Revenue Cycle / Business Office Contact

Name
Name
First
Last

Authorized Signature

Signature

Please contact bobbie.orchard@wha1.org if you prefer to sign via PDF or hard copy application.

Name
Name
First
Last