Breadcrumb Home Delta Region Community Health Systems Development (DRCHSD) Program Application Delta Region Community Health Systems Development Application Organization Name and Address Organization Name Physical Address Please include suite on a second line City StatePlease select... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code County / Parish Website Chief Executive Officer Information Communication about this application will be directed to the CEO. First Name Last Name Title Direct Phone You may provide extension information in this field. Cell Phone Email Address Confirm Email Address Email Error Message CEO Name-Email Chair of the Board of Directors Information Does the organization have a Board of Directors?Please select... Yes No If an additional contacts exists, they will be copied on communication related to this application. First Name Last Name Title Cell Phone You may provide extension information in this field. Email Address Confirm Email Address 3rd Email Error Message Third Name-Email Administrative Assistant Information Does the CEO have an Administrative Assistant?Please select... Yes No If an administrative assistant exists, they will be copied on communication related to this application. First Name Last Name Title Phone Email Address Confirm Email Address AA Email Error Message AA Name-Email Organization Information Type of OrganizationPlease select... Acute Prospective Payment System (PPS) - Hospital Critical Access Hospital (CAH) Federally Qualified Health Center (FQHC) Rural Emergency Hospital (REH) Rural Health Clinic (RHC) - Independent Clinic Rural Health Clinic (RHC) - Provider Based Clinic Other "Critical Access Hospital (CAH)" ( is a certification or designation defined by Medicare. Does your organization meet this criteria? YesNoI don't knowIf you are unsure, additional details are available at the Rural Health Information Hub's Topics List. "Federally Qualified Health Center (FQHC)" is a certification or designation defined by Medicare. Does your organization meet this criteria? YesNoI don't knowIf you are unsure, additional details are available at the Rural Health Information Hub's Topics List. "Rural Health Clinic (RHC) - Independent Clinic" is a certification or designation defined by Medicare. Does your organization meet this criteria? YesNoI don't knowIf you are unsure, additional details are available at the Rural Health Information Hub's Topics List. "Rural Health Clinic (RHC) - Provider Based Clinic" is a certification or designation defined by Medicare. Does your organization meet this criteria? YesNoI don't knowIf you are unsure, additional details are available at the Rural Health Information Hub's Topics List. "Rural Emergency Hospital (REH)" is a certification or designation defined by Medicare. Does your organization meet this criteria? YesNoI don't knowIf you are unsure, additional details are available at the Rural Health Information Hub's Topics List. Describe the Type of Organization Describe the health care service(s) that are provided to the community Number of Licensed Beds beds Number of Staffed Beds beds OwnershipPlease select... County Owned and Operated Governmental Hospital District System Owned and Operated Other Other Public Ownership Physician Owned and Operated Private Equity Ownership Other Private Ownership Non-Profit Describe who owns and operates this organization Define what system Are you affiliated with a system?Please select... Yes No Define the system and describe the affiliation agreement Does your organization operate under a management company?Please select... Yes No Define the management company and describe the management agreement How long has this organization served the community? Application Information Current Participation in Other ProgramsPlease check all the programs that your organization is currently participating in. Small Rural Hospital Improvement Grant Program (SHIP) Medicare Rural Hospital Flexibility (Flex) Program Rural Health Providers Transition Project (RHPTP) Rural Emergency Hospital Technical Assistance Center (REH-TA Center) Targeted Technical Assistance for Rural Hospitals Program (TTAP) Rural Hospital Stabilization Program (RHSP) USDA Rural Hospital Technical Assistance Appalachian Regional Healthcare Technical Assistance Center (ARH-TAC) Northern Border Regional Technical Assistance Center (NBR-TAC) Network Development Small Hospital Quality Program Other Programs Please specify other program Geographical Location My organization is located in a Health Professional Shortage Area (HPSA) as deemed by the U.S. Department of Health and Human Services?Please select... Yes No Unsure My organization is located in a Medically Underserved Area as deemed by the U.S. Department of Health and Human Services?Please select... Yes No Unsure Need for Technical Assistance The DRCHSD Program technical assistance services are designed to: Improve financial, operational and quality performance. Expand telehealth and other existing services or develop new ones. Engage the community to support the organization and enhance care coordination. Promote and market services to increase patient volume and reduce bypassing. Build workforce capacity and develop leadership skills. What is your vision for how the DRCHSD Program can help your organization to: 1. Improve performance and quality of care? 2. Improve services to meet the community's needs? 3. Engage your community? How can the DRCHSD Program help your organization to: 1. Improve financial position? 2. Address profitability and liquidity concerns? 3. Address challenges that may affect access to local services? Memorandum of Understanding (MOU) Is the CEO willing to sign the MOU?Please select... Yes No Is the Chair of Board of Directors wiling to sign the MOU?Please select... Yes No Participation Expectations I have read, and am in agreement with, the Participation Expectations. I understand that the participation expectations are the basic necessities that my hospital must be willing and able to meet to fulfill DRCHSD purpose and goals and maximize benefits to the hospital and community.YesNo Selection for Technical Assistance I understand that submission of this application, nor the confirmed receipt of it, does not guarantee my organization will be selected for technical assistance.Please select... Yes No DRCHSD Program Contact Information The CEO will receive an email confirmation that the online application was successfully submitted. If you have any questions, please email drchsd@ruralcenter.org.