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Name of Chair
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Head Administrator
Institution Name
Hospital Organization:
Free Standing
Hospital within Hospital
Are You:
School-Based
Hospital-Based
Department’s Annual Operating Budget (no punctuation):
$
Number of Clinical Trainees (no punctuation):
Total External Research Funding (no punctuation):
$
Total Annual Outpatient Visits (no punctuation):
Total Inpatient Beds (no punctuation):
Payer Mix – Medicaid:
%
No
No (please provide name, title and email of head administrator)
Head Administrator Info
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Email
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