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IPG Interest Form

Identified Participant Groups (IPGs) Interest Form

Select Identified Participant Groups (IPGs)

Appropriate Care Measures

Health Information Technology

Surgical Care Improvement Project

Organizational Safety Culture Change Project

Name of Hospital

Suggested Contact Person for IPG

Telephone of Contact Person

Fax

E-mail of Contact Person

Who Filled Out This Form? HCQIP Liaison's Name

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