Facilities Form Facilities Facility Name * Health System Name (if applicable) Facility Main Info Enter the primary facility info here. You will have an opportunity below to enter information for specific programs (e.g. screening) if they have are different than the main facility info. Enter Main Address or Facility Name * Enter Main Address or Facility Name Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Enter Main Address or Facility Name Facility Email Facility Phone * Main Website URL * More Facility Info Facility Type * Academic Medical CenterCommunity Hospital - Non-TeachingCommunity Hospital Teaching/AMC AffiliatedAmbulatory ClinicVA Medical CenterOther Federal Government HospitalOther Facility Type Setting * UrbanUrban with broad catchmentRuralFrontierOther Setting Service Location * HospitalOff Campus/Free-Standing Outpatient Hospital FacilityIndependent Diagnostic Imaging FacilityFederally Qualified Health CenterMobile UnitOther Service Location Location User Permissions Add users who can access and manage this facility. Both Admins and Managers can edit facility info and apply for designations. Only Admins can add new Admins and Managers. You should have at least one Facility Admin. Role Facility AdminFacility Manager User ID plus1 Add minus1 Remove Facility Photo Facility Photo Drop a file here or click to upload Choose File Maximum file size: 2MB Adding a photo is optional. A horizontal photo works better than a vertical one. The photo should be at least 800 pixels wide. How to Add a Facility Photo Click here to search for images of your facility. Browse the search results and click on an image you like. It will appear larger on the right side of the page. Check the image dimensions (shown in the lower right corner when you hover over the image). Aim for an image width of at least 800 pixels. Click the blue "Visit" button to go to the source website. On the source page, right-click the image and select "Save image as..." to download it to your computer. Return to this form and drag the saved image into the "Drop a file here..." area. Adding a photo will help you quickly identify your facilities in your member dashboard. It's a great way to personalize your account! Designation-specific Info This section is for information specific to individual designations that differs from the main facility details. For example, you might add a separate address for a screening center or a unique phone number for scheduling. IMPORTANT: Only enter information that differs from the main info above. Do not enter any information that is the same as the main facility info - just leave those fields blank. Designation ScreeningCancer CareIncidental Pulmonary NodulesBiomarker Testing Enter the Address Enter the Address Address Line 1 Address Line 1 Address Line 2 Address Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Enter the Address Email Phone URL plus1 Add minus1 Remove Submit Submit If you are human, leave this field blank.
