JOIN YOUR COLLEAGUES AND ENROLL IN THE STAND UP FOR PATIENT SAFETY PROGRAM TODAY!

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YES, I WANT TO JOIN NPSF'S STAND UP FOR PATIENT SAFETY PROGRAM AS A

• 100+ Beds : $5,000
• 1-99 Beds: $1,500

NAME OF HOSPITAL  _____________________________________________

CONTACT PERSON _____________________________________________

TITLE _____________________________________________

ADDRESS _____________________________________________

CITY ________________________ STATE _________________ ZIP __________

PHONE _____________________ FAX __________________

EMAIL __________________________________________

SIGNATURE _____________________________________

Accounts Payable Manager

Contact Person ___________________________________________________

Title ______________________________________________________

Address __________________________________________________________

City ________________________ State _________________ Zip ____________

Phone _____________________________ Fax ___________________________

Email _____________________________________________________________

PLEASE MAKE CHECKS PAYABLE TO NATIONAL PATIENT SAFETY FOUNDATION

Please contact The National Patient Safety Foundation for more information about NPSFs Stand Up for Patient Safety Program and how your organization can join.

Email: standup@npsf.org

Fax or mail this form to:
National Patient Safety Foundation
268 Summer Street 6th Floor Boston, MA 02210
Phone: 617-391-9900 Fax: 617-391-9999

Qualified organization insure by Lexington Healthcare for medical liability coverage have a unique opportunity. Lexington Healthcare will support your organization’s participation in the Stand Up program by providing a malpractice insurance premium credit in the amount of the program enrollment or renewal fee.