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To more quickly identify your needs and better facilitate your request, we will first ask you a short series of questions about your practice or facility.

Is this application for a hospital or an ancillary facility (e.g. Alcohol/Drug Center, Ambulance Service, Ambulatory Surgery, Audiology, Dialysis Centers, Durable Medical Equipment, Home Health Care, Hospice, Hospitals, Infusion Therapy, Laboratory, Physical/Occupational Therapy, Prosthetics/Orthotics, Radiology Center, Sleep Disorder, Speech Therapy or Urgent Care)?