The Harold P. Freeman Patient Navigation Institute

The Harold P. Freeman Patient Navigation Institute is currently accepting student applications for the following dates: March 10-12, April 7-9, May 26-28, and June 16-18. Space is limited. To apply, please fill out the following form and click submit. A Patient Navigation Institute representative will contact you shortly.

Fields marked with a * are required.

Application Form:

I am interested in:* March 10-12, 2010 April 7-9, 2010 May 26-28, 2010 June 16-18, 2010
Participant Information:
Name:*	Company/Organization: Public    Private
Title:*	Gender: Male    Female
Street Address:	City:
State: Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington,D.C. West Virginia Wisconsin Wyoming	Postal Code/Zip:
Email:*	Phone:*
Mobile:	Fax:
Facility's Information:
Name of Facility: Public    Private    Profit    Non-Profit
Annual Visits of Population Served:
Year Founded:
Address: Same as Above
Street Address:	City:
State: Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington,D.C. West Virginia Wisconsin Wyoming	Postal Code/Zip:
Staff Composition (Number of Employees):
Volunteers (#):	FTE:
Population Ethnicity (%):    White:    Black:    Latino:    Other:
Insurance Coverage %:    Private:    Public:    Uninsured:
How would you rate the Guest/Patient experience at your facility: Poor    Fair    Good    Excellent
Funding Sources:
Do you currently have a Patient Navigation Program? Yes    No If Yes: When was it started? How many (FTE) Patient Navigators? Have they received prior formal training? Yes    No When: Where:
Have you previously applied to HPFPNI? Yes    No	Scheduling:
Anticipated Training Month:
Referrals:
Name:	Title:
Company:	Phone:
Questions/Comments:
Are you ready to submit application?
Please re-type your name:*	Date of Application:

Student/Alumni Login Form:

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Harold P. Freeman Patient Navigation Institute

2002 Fifth Avenue
New York, New York 10027
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Tel.: 212-537-5500
Fax: 212-537-5188
info@hpfreemanpni.org

© 2009, Harold P. Freeman Institute for Patient Navigation, Harold P. Freeman Patient Navigation Program/Model, Patient Navigation - All Rights Reserved.