OKHISPC Volunteer form

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Steering Committee Meetings**

OKHISPC Volunteer form

To join the Stakeholder Community, please provide us with your contact information. We would also like to know the level of involvement you desire and the nature of your experience with health information and health care issues.

Please note that fields indicated with a red asterisk (*) are required.

Contact Information

*First Name:
*Last Name:
*Company, Org., or Agency:
*Title or Position:
*Business Phone No. w/ext. (please include area code):
Business 2nd Phone No./Cell Phone No. (please include area code):
Business Fax No. (please include area code):
*E-mail address:

*What is your interest and experience in working in health and/or information technology? (Please respond in 50 words or less)

*Role

Please tell us your role with regard to health care and health information or the nature of your experience with health care-related issues. For each checkbox you select, please enter the name or specific type of company, organization, or group with which you are involved.

Consumer or consumer organizations (if part of a consumer group, please specify)

Physician Groups

Clinicians

Payers

Community Medical Service Groups
      Hospitals
      Community Clinics and Health Centers
      Pharmacies
      Laboratories
      Long term care facilities and nursing homes
      Homecare and hospice

Medical and Public Health Schools

Public Health Agency

State Government

Professional Associations and Societies

Federal Health Facilities

Correctional Facilities

Quality Improvement Organizations

Other : (Please list)

Are you a Health IT Professional?

Are you a Legal Professional?

How did you hear about the OKHISPC Project? (If other, please specify)

By clicking "Join the Stakeholder Community", I understand that due to the public nature of the OKHISPC project my name may be used in the project's printed or on-line material.

(**) You will need Adobe Reader to open the linked files. Click the logo for the free download.

If you have any questions or comments regarding the OKHISPC Project, please contact Carrie Kardaras by phone, (405) 271-2114 or email, okhispc@ouhsc.edu

Home | Information Packet / Reports | Add Business Practice Steering Committee Meetings**