THA Sanctions Data Bank Subscription Form
Print and Mail this form to THA
Use as part of your
Compliance Program –Review of Cumulative Sanctions, a requirement in the February
1998 OIG Compliance Program for Hospitals. Just print the query report for documentation
of your search.
Convenient Internet Access –
Just choose THA Sanctions Databank on the THA home page at www.tha.com. Provides
convenient access from any area of your facility any time of day.
Easy database query – No need to
handle monthly paper reports.
Cost effective – Less costly
than maintaining your own database. Eliminates the need for monthly downloading,
unzipping, formatting, editing and distribution of the data.
Institution Name: ____________________________________________ Subscriber Mailing Address:_____________________________________ City/State/Zip ____________________________________________ Facility Key Contact Name: _____________________________________ Contact’s Phone (_______)_____________ Contact’s Fax: (_______)_____________ Contact’s E-mail address: _______________________________________ Annual Subscription Fee $__________ Add 8.25% sales tax or provide tax exempt number __________ (tax on $240.00 is $19.80) Grand Total $__________ |
Mail to: THA
Accounting Department 500 Interstate Blvd., South Nashville, TN 37210-4634 Credit Card and Purchase order information may be faxed to: THA Sanctions Data Bank (615) 256-5753 __I authorize payment by: __MasterCard __VISA ___________________________ Credit Card #_______________________ Exp. Date _____________________ Code # 1609.57 revised May 1998 |