Information Request Form

Organization Type:

Please choose your organization type

Product List:

Please choose which services that you would like information about
Assessment, Consultation, and Evaluation Services (ACES)
Community Health Assessment
Patient Satisfaction Survey
Comparative Occurrence Reporting Service (CORS)
Physician Peer Review Service (PPRS)
Quality Management Skills Development Service
Educational Conferences

Requestor Information:

Organization Name:
Bed size:
Name:
Title:
Address:
City/State	Zip
Telephone:	Ext Fax
Email:

Part of system? YES NO

If yes, name of system:

How did you hear about IQH?

Are there any concerns that your facility is facing that IQH can help you with?

Is there any additional information we can send, that may be of interest to your facility?

Additional comments: