Registration Form

*Username/Email:

*Password:

*Confirm Password:

*First Name:

*Last Name:

*Title:

*Telephone:

*Are you requesting information on behalf of your hospital ?:

*Facility Type:

If Other Specify:

Facility Demographics:

Facility Setting:

Number of Hospital Beds:

Please enter a value for Facility Network

Facility Health System/Network:

*Facility Country:

*Facility State:

Please enter a value for Please Select Facility Name

Please Select Facility Name, if facility is not listed enter the facility name in next section:

Facility Address 1:

Facility Address 2:

Facility City:

Facility ZIP/Postal Code:

Please enter a value for Verify Facility Address, if not found please manually enter address fields and do not reclick checkbox

* Verify Facility Name and Address by clicking checkbox. If your facility was not found in the dropdown list, please manually enter address fields below and do not reclick checkbox:

*Facility Name:

*Facility Address 1:

Facility Address 2:

*Facility City:

Please enter a value for Facility Zip Code

*Facility Zip/Postal Code:

Please select a value for Participate with ACC-NCDR

*Does your hospital participate with the ACC-NCDR:

If you answered 'Yes' above, please select all registries that apply:

ACTION Registry - GWTG:

CathPCI Registry:

CARE Registry:

ICD Registry:

NCDR Hospital ParticipantID:

IC3 Medical PracticeID:

As a participant in the Hospital to Home(H2H) Program, I agree to the following:

*I agree that my facility is committed to the program goal - to reduce preventable, all-cause hospital readmissions for patients discharged with a cardiovascular diagnosis :

I agree
I disagree

Please select a value Implement Strategies

*I will attempt to implement the recommended strategies for achieving the program goal :

I agree
I disagree

Please enter a value for Promotional Efforts

*I permit the ACC to use my facility’s name in its public list of participating facilities and in any promotional effort related to the H2H Program :

I agree
I disagree

*I agree to complete up to three H2H participant surveys to provide information on the processes my facility is using to reduce preventable hospital readmissions :

I agree
I disagree

Please enter a value for Facility Stories

*I agree to participate in the H2H online community by sharing with other participating facilities stories, successes, barriers, experiences, tools and/or resources :

I agree
I disagree

Please enter a value for Facility Readmission

*I understand that ACC will not identify hospitals when it publishes information on facility readmission rates or other data, unless expressly permitted by the facility :

I agree
I disagree