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CBISA™ Order Form

Add-On Hospital Order Form

Unit Name *Name of your unit, up to 50 characters
Number of Beds *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
County *
Would you like your database pre-populated with standard programs? *
YesNo
Are you a member of a State Hospital Association? *
YesNoI don't know
Are you a member of CHA? *
YesNo

Community Benefit Team

System Name *
Coordinator *This will be the person in charge of your community benefit efforts
Job Title *
Phone *
Email *
Additional Team Member
Job Title
Phone
Email
Additional Team Member
Job Title
Phone
Email

Billing Information

Is the billing contact different than System Administrator? *
YesNo
Billing Contact (if different than System Administrator) *
Phone *
Email *
Billing *
With SystemIndividually
Your System Administrator will receive an email when your site is available.
Where did you hear about us? *Please let us know where you heard about CBISA.

Person Completing The Form

Name *

Email *

Please enter any two digits *
This box is for spam protection - please leave it blank

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