STEMI Center Recognition Request

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

1 Have ready: Official certificate of accreditation or certification
2 Complete the application
3 Email or mail a copy of the official certificate (addresses listed below)
4 After we receive your certificate and application, we will email you
5 View your facility on the STEMI map (link will be in the recognition email)

Contact us with any questions or concerns:
lisa.domenico@state.co.us
720-413-6469

A copy of the official certificate is required to be mailed or emailed in pdf format to complete this application. *

Please check the box that this step is complete

I have emailed my official certificate.

Required

Facility name *

Facility address *

Facility web address

Facility phone number *

Facility contact person *

Facility contact email *

Alternate contact person *

Alternate contact email *

Alternate contact telephone *

Check all certification/accreditations that apply

American Heart association, Mission:Lifeline accreditation

STEMI Receiving Center

STEMI Referring Center

ACC Accreditation Services

Chest Pain

Chest Pain with Primary PCI

Chest Pain with Primary PCI and Resuscitation

Joint Commission

Chest Pain Center

Other

Certification organization and title

Certification Expiration Date(s) *

Application Completion

Email certificate in pdf format to:
lisa.domenico@state.co.us

OR Mail to:
Attention: Lisa Domenico
4300 Cherry Creek Drive South/ HFEMSD/EMTS
Denver, Co 80246-1530

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of State.co.us Executive Branch.

Does this form look suspicious? Report

Forms