Agency/Facility Type City Government County Government State Government College/University Adult Day Care Center Ambulatory Care Center Assisted Living Auditorium/Museum Behavioral Health - Inpatient Behavioral Health - Outpatient Camp Casino Catering Charity Children's Medical Closed Door Pharmacy Community Health Center Cont Care Retire Comm Convention Center Critical Access Hospital Day Care Dentistry Dialysis Center DME & Supply Dealer Employee Feeding Eye, Ear, Nose and Throat First Responder Freestanding Healthcare Lab General Medical and Surgical Hospital Golf Course/Country Club Head Start Health Plan/HMO/PPO Healthcare Corporate Office Healthcare Day Care Healthcare Gift Shop Healthcare Laundry Services Healthcare Management Svc Org Healthcare Warehouse/SupplyCtr Home Health Care Agency Home Infusion Hospice - Home Care Hospice - Inpatient Hotel/Motel Imaging Center Independent Living K12 private K12 public Long Term Acute Care Mail Order Pharmacy Maternity Hospital Meals on Wheels Medical Association Non-Healthcare Corp Office Non-Healthcare Mgmt Svc Org Oncology Center Orthopedic Hospital Other Hospital Park/Recreation/Fairgrounds Pharmacy Physician Prison/Correctional Health Psych/Mental Health Hospital Public Health Department Rehabilitation Center Religious Institute Retail Pharmacy Skilled Nursing Stadium/Arena Student/Employee Health Svc Substance Abuse Treatment Ctr Surgery Center Veterinary Wellness Facility/Fitness Ctr Zoo Other
The individual who submits this form on behalf of the Roster Participant represents and warrants that he/she is duly authorized to bind the Roster Participant to the Terms and Conditions of Participation as indicated above.