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  QUALITY ASSURANCE - PROVIDER DETAILS FORM
  Name of Hospital 
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  Address of Hospital   Telephone Numbers
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  How long have you been with THT?
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  How many THT Enrollees do you have
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  Are you satisfied with the relationship so far?   Yes     No
  If No, Why?  
  What do you wish THT should do to improve the relationship?
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  Do you wish to continue as a THT Provider Hospital?   Yes     No
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