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Basic Info

First Name

Last Name

Full Name

* This is used on your certificate.

Email Address

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Password

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Address Info

Address 1

Address 2

City

State/Province

Zip Code

Zip code must contains 5 digit of numbers *

Country

Work Phone

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Home Phone

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User Profile

* indicates required field

Company Name (Enter N/A if not applicable):*

Company Type (check only one):*

Home-Based Primary Care (HBPC) Practice, independent

Home-Based Primary Care (HBPC) Practice, affiliated with Hospital/Health System

Office- or Clinic-based Primary Care Practice, independent, solo or group

Office- or Clinic-based Primary Care Practice, affiliated with Hospital/Health System

Hospital/Health System, without HBPC

Hospice/Community-based Palliative Care Organization, with HBPC

Hospice/Community-based Palliative Care Organization, without HBPC

Government Agency (e.g. VA, FQHC)

Home Health Company

Research/Academia

Professional/Membership Organization

Industry (e.g. Pharmaceutical, Device Manufacturers)

Press/Media

Other (specify)

Job Title (enter N/A if not applicable):*

Credentials (enter N/A if not applicable):*

Practice Size:*

As a nonprofit, HCCI is able to offer its education and other services at affordable rates due, in part, to philanthropic giving. Much of the work is dependent on these generous gifts, and having your NPI number helps us demonstrate the impact of our work (e.g., more patients being served, more providers making home visits, etc.). HCCI does not handle any protected health information; any/all data collection and analysis is conducted in the aggregate. Thank you in advance for providing your NPI to us for this purpose.*

I do not have an NPI.

I prefer not to share my NPI.

I have provided my NPI below.

National Provider Identifier (NPI):

In what year did you begin working in HBPC, on at least a half-time basis?*