MEDICAL FACILITY REGISTRATION FORM
(PLEASE USE UPPER CASE)
DateTime
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Month
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Day
Year
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
FACILITY NAME
*
FACILITY ALIAS
FACILITY MAIN PHONE LINE, GENERAL
*
FACILITY EMERGENCY LINE
*
ADDRESS
*
LONGITUDE / LATITUDE
MEDICAL DIRECTOR NAME
MEDICAL DIRECTOR CONTACT (EMAIL AND/OR PHONE)
ADDITIONAL PHONE CONTACT 1
NAME/NUMBER
ADDITIONAL CONTACT 2
NAME/NUMBER
ADDITIONAL CONTACT 3
NAME/NUMBER
ADDITIONAL CONTACT 4
NAME/NUMBER
FACILITY TYPE
*
Please Select
Hospital with ER, Onsite ER Doc 24/7
Hospital no ER 24/7
Hospital with no ER, Hours Limited
Out Patient Clinic, Permanent
Out Patient Clinic, Rotation/Temp
Pharmacy Only
Lab Only
CT/Xray Only Center
FACILITY SPECIALTY
*
Please Select
TRAUMA
PEDIATRIC
OBSTETRICS/GYNECOLOGY
MALNUTRITION
INFECTIOUS DISEASE
OPHTHALMOLOGY
DENTAL
ORTHOPEDICS
BURN CENTER
PSYCHIATRY
NEUROLOGY
SPINAL CORD INJURIES
DIALYSIS
PULMONARY CARE
CARDIOLOGY
LABORATORY
OTHER CAPABILITIES (CHECK ALL THAT APPLY)
TRAUMA
PEDIATRIC
NICU / PICU
OB / GYN
MALNUTRITION
INFECTIOUS DISEASE
OPTHALMOLOGY
DENTAL
ORTHOPEDICS
BURN CARE
PSYCHIATRY
NEUROLOGY
SPINAL CORD INJURIES
DIALYSIS
PULMONARY CARE
CARDIOLOGY
LABORATORY
VENTILATOR BEDS
ICU
CT SCAN
X-RAY
AMBULANCE
Carries Rabies Vaccine/Serum
IS THIS HOSPITAL PARTNERED WITH ANY OTHER FACILITIES OR MEDICAL SERVICE PROVIDERS?
FINANCE (CHECK ALL THAT APPLY)
*
CHARITY, NO / LOW FEE
PRIVATE, DEPOSIT REQUIRED
PRIVATE, NO DEPOSIT REQUIRED
ACCEPTS AIC
ACCEPTS NASSA/INASSA
ACCEPTS INTERNATIONAL INSURANCE (EXPLAIN BELOW)
ACCEPTS OTHER LOCAL INSURANCE (EXPLAIN BELOW)
ACCEPTS OFATMA
NO PUBLIC ACCESS (UN, EMBASSY, ETC ONLY)
PUBLIC, GOVERNMENT OPERATED
SOCIAL WORKERS AVAILABLE (FINANCE RELATED)
ONSITE ATM
COMMENTS (FINANCE)
GENERAL SUPPORTING DOCUMENTS 1
Title of Document (1)
GENERAL SUPPORTING DOCUMENTS 2
Title of Document (2)
GENERAL SUPPORTING DOCUMENTS 3
Title of Document (3)
PHOTO 1 (ER, LAB, ETC)
Describe Photo (1)
PHOTO 2 (ER, LAB, ETC)
Describe Photo (2)
PHOTO 3 (ER, LAB, ETC)
Describe Photo (3)
FORM PREPARED BY:
*
First Name
Middle Name
Last Name
I certify
*
I certify that I have personally verified the information above to the best of my ability
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