Please review the membership profile process here prior to applying.
Check all that apply.
Ambulatory Surgical CenterAssisted Living / Long Term Care / Skilled Nursing FacilityBehavioral Health - InpatientBehavioral Health - Outpatient / Community Mental Health CentersDialysisEmergency Department / Emergency Center / Free-Standing ED / Urgent Care (not part of a hospital)Emergency ManagementEmergency Medical Services (EMS)Fire DepartmentHome Health / Visiting NursesHospiceHospital - Acute CareHospital - Critical AccessHospital - Non-Acute CareHospital - Trauma CenterIntermediate Care Facility for Individuals with Intellectual DisabilitiesLaw EnforcementOutpatient Services (Primary Care, Community Health Center, Specialty Clinic, Rural Health, FQHC, Rehab, etc.)Outpatient Physical Therapy / Speech-Language PathologyPharmacyPublic / Environmental HealthReligious Non-Medical Health CareTransplant CenterOther HCC Partner Organization
If your agency serves more than one county, please select all that apply.
Emergency Contact Cell Number
Organization Mailing Address*
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