Participant Intake Form

General Information

* Organization Name

* Group or Facility NPI number

* Business Legal Name

* Main office phone number

* Address Line 1

Address Line 2

* City

* State

* Zip Code

* County

Primary Contact

* Full Name

* Title

* Phone Number

* Email Address

Secondary Contact

* Full Name

* Title

* Phone Number

* Email Address

KHIE Champion Contact Name and Title

Who is the KHIE Advocate or primary KHIE Supporter in your Organization? Who ensures that your organization is informed about KHIE?

* Full Name

* Title

* Phone Number

* Email Address