Organizational flowdown membership

Organizational or Indiana Statewide Rural Health Network (InSRHN) Members

Please proved the contact information of the individuals within your organization who you would like to receive IRHA member benefits. Please provide the correct email address for each individual (do not share an email address), the email address will become the user ID and cannot not be shared.

This form allows up to five employees to be listed, you do not have a limit on the number of employees you can provide. If you want to add more than 5 employees please submit the form with the first five and then submit another form until you have all employees you want listed.

Organizational memberships only cover individuals in your facility/campus; it does not cover individuals or facilities located off your campus.

If your hospital holds an InSRHN membership, the hospital's membership will cover clinics owned by the hospital located off your campus. This benefit is an InSRHN member benefit only.
If an InSRHN hospital owns a clinic they would like to add, please indicate it on the form so IRHA can properly record the information to put the clinic under the hospital.

 

Name of organization
Is your hospital an InSRHN member?
 Yes
 No

First Name
Last Name
Title
Email
Phone

#2 -First Name
#2 -Last Name
#2 -Title
#2-Email
#2-Phone

#3 -First Name
#3 -Last Name
#3 -Title
#3-Phone
#3-Email

#4 -First Name
#4 -Last Name
#4 -Title
#4-Email
#4-Phone

#5 -First Name
#5 -Last Name
#5 -Title
#5-Email
#5-Phone