Rural Health Policy Hospital Application Form
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Rural Hospital Performance Improvement Project
Application

Delta Eligible Hospitals

Delta eligible hospitals and waiver eligible hospitals may apply for on site technical assistance services through the RHPI Project. For selection criteria please see Selection Considerations and check the Eligible Hospital List for your state.

Online Application

To apply for on site consultation services, please complete this form and submit the application online to the RHPI Project. Your request for consultation will be reviewed, and a follow-up telephone call will be conducted to discuss the request.

Hospital Name:
Address:
City:
State:
ZIP:
County / Parish:
Telephone Number:
Fax Number:
Hospital Administrator / CEO:
Telephone Number:
Fax Number:
E-mail:
Board Chair / President:
Telephone Number:
Fax Number:
E-mail:
Number of Beds:
Annual Net Revenues:
Annual Expenses:
CAH Year Converted to CAH:

The RHPI Project can provide on site technical assistance through consultation services in a wide range of areas. Below is a list of categories in which the RHPI Project may assist hospitals. Please check the box for each category that is a need for your hospital.

Leadership




Strategic Planning



Customer and Markets




Measurement and Knowledge Management




Human Resources



Process Management












Please describe what you expect from the consultation. How do you expect the consultation to help you?

Have you previously participated in the RHPI project?

If you have previously participated in the RHPI project, please share the program successes and/or feedback from the consultation.

By providing an online signature and date below, the Administrator / CEO acknowledges that he/she will inform the Board Chair and Board of Directors of this application for RHPI Project participation. The purpose of this is to ensure that the Chairperson / President of the hospital's board of directors or trustees are informed that the hospital is submitting this application.

Hospital Administrator / CEO
Date
Board of Director Chairperson / Trustee Chairperson / President*
Date

FOR MORE INFORMATION:
Contact Bethany Adams
Delta RHPI Program Manager
Mountain States Group
1607 W. Jefferson St
Boise, ID 83702-5111
Phone: 904.553.0081
badams@mtnstatesgroup.org