FRCE Interest Form

Florida Regional Resuscitation Center of Excellence (FRCE) Interest Form

Thank you for your interest in becoming a designated Florida Regional Resuscitation Center of Excellence (FRCE). This initiative aims to enhance patient outcomes through a coordinated system of care for cardiac resuscitation. Please provide the following information to help us understand your hospital’s interest and readiness to participate. NOTE: FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
Facility Information
Hospital/Facility Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Contact Information
Primary Contact Name

First NameLast Name
Credentials
Job Title/Role
Department (e.g., Emergency Medicine, Cardiology, Administration, etc.)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Senior Administrator/CEO Contact Information

FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
Senior Admin/CEO Name

First NameLast Name
Senior Admin/CEO Email
example@example.com

EMS Agency Information

FRCE designation is dependent on submission of an official FRCE letter of attestation signed by the hospital CEO and local EMS Medical Director.
EMS Agency Name
If multiple local EMS Agencies transport patients to your hospital, list all agencies above. We will email you a customized letter of attestation based on the information provided here.
EMS Agency Name
If multiple local EMS Agencies transport patients to your hospital, list all agencies above. We will email you a customized letter of attestation based on the information provided here.
EMS Medical Director

First NameLast Name
EMS Medical Director Email
example@example.com

Please leave comments, feedback, or describe any unique challenges or needs.
Please attach any additional information or documents that support your hospital's interest (optional).

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Next Steps:

Once your form is submitted, a member of the FRCE team will contact you to discuss your hospital's participation and the next steps in becoming a designated Resuscitation Center of Excellence.

Access the FRCE Tool Kit and Resources at www.faemsmd.org/FRCE if you have not done so already.
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Florida Regional Resuscitation Center of Excellence (FRCE) Interest Form