Institute for Behavioral Healthcare Improvement

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IBHI ED Collaborative Enrollment Form 2008

Step 1. Fill out the Registration Form below. Deadline for enrollment is December 14, 2007.

Step 2. Pay for your IBHI registration.

IBHI ED Collaborative Enrollment Form 2008

* indicates a required field

* IBHI Membership Status New Member Current Member

Organization Information

* Organization Name
System Parent Organization Name
Organization Website

* Hospital Demographics Rural Urban Suburban

* Type of Organization (Please check the appropriate box(es) and fill in all necessary fields)

Hospital
HMO
Integrated Delivery System:
Medical Group
Community Based Provider Group
Other:

* Ownership Type Public Private

Hospital Information

Number of Beds
Number of Physicians
Number of Employees
Medicare Number

* How did you hear about us? (Please check the appropriate box(es) and fill in all necessary fields)

Current IBHI Member
Website
From an IBHI Member
Email
Info Call
Other:

Please tell us what you would like to get from this pilot collaborative (in about 100 words.)

Definitions

Key Contact
The Key Contact is the “owner” of the organization’s Community participation.

Team Leader
The Team Leader is the day-to-day leader who will lead the team in idea generations, testing, and implementation on the test site as well as work with the Sponsor on spread strategies.

Sponsor
The Sponsor is the leader who is responsible and accountable to the organization for the performance and results of the community improvement team. This person is not a member of the team, but is responsible for securing the resources for the team to accomplish their aim and communicating their progress to other leaders in the organization.

* Key Contact (Main Contact)
* Address
* City, State, Zip Code
* Country
* Phone
Fax
* Email Address

* Secondary Key Contact (Back-up for Main Contact)
* Address
* City, State, Zip Code
* Country
* Phone
Fax
* Email Address

* CEO Name
* Phone
Fax
* Email Address

* Billing Contact (if different from Key Contact)
* Address
* City, State, Zip Code
* Country
* Phone
Fax
* Email Address

* Team Leader
* Address
* City, State, Zip Code
* Country
* Phone
Fax
* Email Address

* Sponsor Name
* Phone
Fax
* Email Address

Pricing
$13,500 each community, per entity, per year. This includes a one year membership in the Institute for Behavioral Healthcare Improvement.

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Revised on April 21, 2008
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