WHA Membership Application

Facility Information

Name of Healthcare Organization *

DBA (if different)

Physical Address *

Mailing Address *

City *

State *

Zip Code *

Phone *

Website *

Number of Licensed Beds

Current FTEs

Critical Access Hospital Designation

Yes

No

Class (acute care, etc.)

System Affiliations

GPO

Dues

We Designate (name) to Attend WHA Board Meetings

Chief Executive Officer Contact

Name

First

Last

Title

Phone

Email Address

Executive Assistant Name

First

Last

Phone

Email Address

Chief Financial Officer Contact

Name

First

Last

Title

Phone

Email Address

Executive Assistant Name

First

Last

Phone

Email Address

Designated Contact with WHA (if different from CEO)

Name

First

Last

Title

Phone

Email Address

Executive Assistant Name

First

Last

Phone

Email Address

Chief Medical Officer Contact

Name

First

Last

Title

Phone

Email Address

Chief Nursing Officer Contact

Name

First

Last

Title

Phone

Email Address

Communications & Marketing Contact

Name

First

Last

Title

Phone

Email Address

Compliance Contact

Name

First

Last

Title

Phone

Email Address

Emergency Department Contact

Name

First

Last

Title

Phone

Email Address

Health Information Management/Medical Records Contact

Name

First

Last

Title

Phone

Email Address

Human Resources Contact

Name

First

Last

Title

Phone

Email Address

Infection Control Director Contact

Name

First

Last

Title

Phone

Email Address

Information Technology Contact

Name

First

Last

Title

Phone

Email Address

Laboratory Contact

Name

First

Last

Title

Phone

Email Address

Materials Management Contact

Name

First

Last

Title

Phone

Email Address

Practice Administrator Contact

Name

First

Last

Title

Phone

Email Address

Quality Improvement / Risk Management Contact

Name

First

Last

Title

Phone

Email Address

Radiology Contact

Name

First

Last

Title

Phone

Email Address

Rehabilitation Contact

Name

First

Last

Title

Phone

Email Address

Revenue Cycle / Business Office Contact

Name

First

Last

Title

Phone

Email Address

Authorized Signature

Signature

I acknowledge that by typing my name below, I am signing this application electronically.

Signature

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

Name

First

Last

Title

Date

By Partner:

By Service:

By Name:

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

Facility Information

Chief Executive Officer Contact

Chief Financial Officer Contact

Designated Contact with WHA (if different from CEO)

Chief Medical Officer Contact

Chief Nursing Officer Contact

Communications & Marketing Contact

Compliance Contact

Emergency Department Contact

Health Information Management/Medical Records Contact

Human Resources Contact

Infection Control Director Contact

Information Technology Contact

Laboratory Contact

Materials Management Contact

Practice Administrator Contact

Quality Improvement / Risk Management Contact

Radiology Contact

Rehabilitation Contact

Revenue Cycle / Business Office Contact

Authorized Signature

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