LifeFlow Challenge Coin Submission Form

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Due to high demand, please limit coin requests to a maximum of six (6) per call. Please prioritize nominations for those most impacted or handling the most critical cases. All nominees will be acknowledged in the letter from Dr. Piehl.

Thank you.

Email *

Submitter full name (first and last):
*

Submitter email:
*

Submitter phone number: *

Submitter rank/title at the organization: *

Does your agency currently use LifeFlow? *

Yes

List full name (first and last), rank, and title of each person you are nominating for a challenge coin for this case (one person per line):
*

Without revealing PHI, please provide a description of the case with as many details as you can provide. Do not include personal identifiers such as name or DOB.
*

What month and year did this event occur? (do not give the specific date) *

May we use this story in our social media posts? *

If "yes", we will be in touch to discuss further details about how to share this story.

Yes

Any other comments or anything else you'd like for us to know? *

A copy of your responses will be emailed to the address you provided.

Submit

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