Thank you for taking time to complete this application. We appreciate your interest in engaging with us to help enhance our patient and family experience. Once your application has been received, you should expect a follow up within 7 days to provide you with next steps and answer any questions you may have.
Please note all members will be required to sign a confidentiality agreement prior to participation.
Once you have completed the application please return to:
Gina Benincasa, Patient Experience Specialist at email@example.com or mail to:
Attention: Gina Benincasa
9400 Zane Ave. N
Brooklyn Park, MN 55443