Breadcrumb Home Delta Region Community Health Systems Development (DRCHSD) Program Application Delta Region Community Health Systems Development Application Organization Information Organization Name Type of OrganizationPlease select... Critical Access Hospital (CAH) Federally Qualified Health Center (FQHC) Prospective Payment System (PPS) - Hospital Rural Health Clinic (RHC) - Independent Clinic Rural Health Clinic (RHC) - Provider Based Clinic Rural Emergency Hospital (REH) Other Number of Licensed Beds beds Number of Staffed Beds beds Describe the Type of Organization 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 County / Parish Chief Executive Officer Information First Name Last Name Title Phone You may provide extension information in this field. Email Confirm Email Email Error Message CEO Name-Email Administrative Assistant Information Does the CEO have an Administrative Assistant?Please select... Yes No First Name Last Name Title Phone Administrative Assistant Email Confirm Email AA Email Error Message Name Match Error Message AA Name-Email Contact Person Communication about this application will be directed to this individual. Who will serve as the primary contact for this application? Please select... CEO Administrative Assistant Another Individual Who will serve as the primary contact for this application? Please select... CEO Another Individual First Name Last Name Title Phone You may provide extension information in this field. Email Confirm Email 3rd Email Error Message AA-3rd Name Match Error Message Third Name-Email 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) Network Development Small Hospital Quality Program Centers for Medicare & Medicaid Innovation (CMMI) Grant Targeted Technical Assistance for Rural Hospitals Program (TTAP) Other Federal Office of Rural Health Policy (FORHP) programs or projects Please specify other FORHP program or project participation Describe the geographic area(s), counties/parishes, cities, or other locations impacted by your healthcare organization. Is the geographic area deemed a Health Professional Shortage Area (HPSA) by the U.S. Department of Health and Human Services? Please select... Yes No Provide a brief narrative describing the technical assistance needed for your healthcare organization. Will the applicant's governing body and/or principal sign a letter of commitment to work closely with HRSA's technical assistance provider(s) to achieve the objectives of the program?Please select... Yes No Please explain Participation ExpectationsPlease select... Yes No I have read and am in agreement with the participation expectations. I understand that the participation requirements are the basic necessities that my health care organization must be willing and able to meet to fulfill DRCHSD Program purpose and goals. Selected organizations are expected to participate in all facets of the DRCHSD Goal areas to fulfill the Program purpose of developing a local system of care.