Home | HISPC Private Workspace Login | Information Packet / Reports | Join the Stakeholder Community | Add Business Practice

Meeting Dates**

 

 

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 Vincent Deberry by phone, (405) 325-0519 or email, okhispc@oucpm.org

 

 

 

 

 

 

Home | HISPC Private Workspace Login | Information Packet / Reports | Join the Stakeholder Community | Add Business Practice

Meeting Dates**