CONTACT MAASC

Name     

Title       

Email      


Postal Address  

City/ Town        


State        

Zip Code   

Telphone   

Fax            

Your company web address

4. What best describes your role in the medical profession? Doctor Nurse Administrative Other

5. Is your center an established center?    Yes No

If no ,when ?

6. Is your facility Massachusetts licensed?    Yes No

If no ,when ?

7. Is your facility Medicare certified?    Yes No

If no ,when ?

8. Is your facility certified by any other agency ?    Yes No

If yes , name of agency?

If no ,when ?

9. What is the number of MDs your facility represents?

10. What is the number of cases provided last year?

11. In order to find out about events and activities in MASS ASC, what sources of communication do you use?

Newspapers  Newsletter Word of Mouth Website Email Other

12. What improvements would you wish to see as a Member of MASS ASC?

13. As we develop our website , are there other items you would like to see on the site ?

The information will be returned via electronic form to the MASS ASC. Please include a copy of the completed company contact information along with your check of $975.00 to: Steven Pimental, 272 Stanley Street
Fall River, MA 02720 Treasurer (508) 672-2290

For more questions about joining MAASC, or ambulatory surgery centers, please contact:

Linda K. Rahm, President (413) 788-9700

Steven Pimental, Treasurer (508) 672-2290

Back to MASS-ASC homepage