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CPD Guy
Get your facility registered immediately and start earning your
SP Ds
today. As soon as we receive your completed application you will be registered and an initial statement will be sent. Summary statements will be sent on a quarterly basis.
Department Manager Name:
Facility Name:
Address:
City:
State:
Zip:
Main Hospital Phone:
Department Phone:
Fax Number:
Email Address:
Immediate Supervisor:
Key Staff:
IAHCSMM:
ASHCSP:
Member Number:
Member Number:
Your Name:
Date:
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