Individual Information: (* = Required)

*First Name:		*Last Name:

*Title:		*Phone Number:
*Email:

Facility Information: (* = Required)

*Are you requesting information on behalf of your hospital?

*Facility Type:

If Other specify:

Facility Demographics:

Facility Setting:

Number of Hospital Beds:

Facility Health System/Network:

*Facility Country:

*Facility State:

* Please Select Hospital Name:

*Facility Name:

*Facility Address 1:

Facility Address 2:

*Facility City:

* Facility ZIP/Postal Code:

*Does your hospital participate with the ACC-NCDR?

NCDR Hospital ParticipantID:

IC3 Medical PracticeID:

As a participant in the Hospital to Home(H2H) Program, I agree to the following:	(* = Required)

*I agree that my facility is committed to the program goal - to reduce preventable, all-cause hospital readmissions for patients discharged with a cardiovascular diagnosis	I agree I disagree
*I will attempt to implement the recommended strategies for achieving the program goal	I agree I disagree
*I permit the ACC to use my facility’s name in its public list of participating facilities and in any promotional effort related to the H2H Program	I agree I disagree
*I agree to complete up to three H2H participant surveys to provide information on the processes my facility is using to reduce preventable hospital readmissions	I agree I disagree
*I agree to participate in the H2H online community by sharing with other participating facilities stories, successes, barriers, experiences, tools and/or resources	I agree I disagree
*I understand that ACC will not identify hospitals when it publishes information on facility readmission rates or other data, unless expressly permitted by the facility	I agree I disagree