New HCC Membership Request Form
Which county is your agency located?
Please Select
Moffat
Rio Blanco
Garfield
Mesa
Routt
Eagle
Pitkin
Jackson
Grand
Summit
Which option best describes your agency?
Please Select
Ambulatory Surgery Center
Assisted Living, LTC, SNF
Behavioral Health Inpatient
Behavioral Health - Outpatient / Community Mental Health Centers
Dialysis
Emergency Department / Emergency Center / Free-Standing ED / Urgent Care (not part of a hospital)
Emergency Management
Emergency Medical Services (EMS)
Fire Department
Home Health / Visiting Nurses
Hospice
Hospital - Acute Care
Hospital - Critical Access
Hospital - Trauma Center
Intermediate Care Facility for Individuals with Intellectual Disabilities
Law Enforcement
Outpatient Services (Primary Care, Community Health Center, Specialty Clinic, Rural Health, FQHC, Rehab, etc.)
Outpatient Physical Therapy / Speech-Language Pathology
Retail Pharmacy
Public / Environmental Health
Transplant Center
Other HCC Partner Organization
Agency Name
Primary Contact Information
First Name
Last Name
What is your primary position or role?
Email
example@example.com
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
-
Area Code
Phone Number
Emergency Phone Number
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Would you like to be added to the Everbridge Notification System? NWRHCC utilizes Everbridge to broadcast urgent messages during an emergency. Please email shilley@nwccog.org if you would like to add multiple members from your organization.
Yes, please use the contact information entered above
No
Submit
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