Heart Attack Center Certification Hospital Lead Form

Name of Hospital or Health System: (required) *

Location City (required) *

Location State (required) *

Name of Requestor (required) *

Title (required) *

Phone Number (required) *

E-mail (required) *

Please select one or more of the following:

Interested in learning opportunities Interested in applying for Primary Heart Attack Center (PHAC) Certification Interested in applying for Acute Heart Attack Ready (AHAR) Certification

Interested in applying for one or more of the individual American Heart Association/American College of Cardiology accreditations:

Chest Pain Center Accreditation Heart Failure Accreditation Atrial Fibrillation Accreditation Cath Lab Accreditation

Please share any additional questions, comments, or suggestions. We’d love to hear from you!