Organizational Information
Please provide details about your organization's hospice and palliative care services.
Company/Organization name
Primary organizational contact name
Primary organizational contact email
Primary billing contact name
Primary billing contact email
Number of employees dedicated to hospice and/or palliative care
Is your organization a non-profit?
Yes
No
Are you currently accepting pediatric patients?
Yes
No
Do you provide hospice care?
Yes
No
Do you provide palliative care?
Yes
No
Number of office or branch locations in Minnesota
Do you currently have staff or volunteers engaged with MNHPC through committee or board membership?
Yes
No
What Electronic Medical Record are you currently using?
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Organizational Information Form