Rural Hospital Stabilization Program Application

Please complete this form to apply to participate in the Rural Hospital Stabilization Program. If you have any questions, please contact us at stabilization@ruralcenter.org.

Hospital Name and Physical Location



Please include suite on a second line





Chief Executive Officer Information
Communication about this application will be directed to the CEO.




You may provide extension information in this field.




Chair of the Board of Directors







Administrative Assistant Information

If an administrative assistant exists, they will be copied on communication related to this application.







Hospital Information
Please see the eligibility requirements for more information.

Bed Size

beds

beds
Ownership



Affiliation




Current Participation in Other Programs
Please check all the programs that your hospital is currently participating in.

Geographical Location


Hospital Need for RHSP Technical Assistance

The RHSP technical assistance services are designed to:

    • Improve financial and operational performance
    • Expand existing services and/or develop new services lines
    • Engage the community and market locally available health care service



Memorandum of Understanding (MOU)

The applicant is expected to sign a Memorandum of Understanding (MOU) to work closely with HRSA's technical assistance provider(s) to achieve the Program’s purpose and goals.  



Participation Expectations

Selection for Technical Assistance

RHSP Contact Information

The CEO will receive an email confirmation that the online application was successfully submitted. If you have any questions, please email stabilization@ruralcenter.org.