NCIOM Safety Net Survey

Please complete the following form for your organization. Once completed, click on the "Save Organization Information" button on the bottom of the page. You will be notified if and when your organization details have been reviewed and accepted. Already Registered? Click here to login. *Organization Name:  Parent Organization Name: *Organization Type: Select from below FQHC or FQHC look alike Local health department Free Clinic State-funded rural health clinic Hospital outpatient clinic AHEC clinic Project Access Other non-profit community organization Community Practitioner Practice site or Other: *Address:  Address 2: *City: * State: <Select a State> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   *Zip Code: *Organization Phone Number: (10 digits and no hyphens [e.g. 9198241337])  Organization Fax: (10 digits and no hyphens [e.g. 9198241337])  Organization E-Mail:  Organization Fiscal Year: Select from below Jan-Dec Jul-Jun Oct-Sept Apr-Mar or Other:  Organization Website: [e.g. www.nciom.org] *Contact Name:  Contact Phone: (10 digits and no hyphens [e.g. 9198241337])  Contact Fax: (10 digits and no hyphens [e.g. 9198241337]) *Contact Email:  Contact Password:  Password Hint: