Custom Mapping

Use the online form to request a high quality map that can show your data with our shortage designation, healthcare workforce, demographic, socio-economic, political, etc. data as seen in the map sample archive.  We can even include your logo for free along with your point of contact and data source since this map will be yours to use freely.

Fee:  A minimum cost of $100 applies to all custom maps. After submitting your request, you will be contacted within 24 hours to confirm your map order.

Custom Map Request Form

*denotes a required field

Contact Information
First Name*
Last Name*
Title*
Organization
Address 1*
Address 2
City*
State*
Zip*
Email*
Phone 1*
Phone 2
Map Information
Map Coverage Area* (Select one )	National (US) Regional State Zip Code or other
Region	Northeast Mid-Atlantic Southeast South Southwest West Midwest
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Professions (select up to 3)	Physicians (Allopathic and Osteopathic) Physician Assistants Advanced Practice Nurses Certified Nurse Anesthetists Certified Nurse Midwives Psychologists Podiatrists Optometrists Certified Nurse Specialists Physical Therapists Dentists Oral Maxillofacial Surgeons Pharmacists Audiologists Speech Language Pathologists Chiropractors Naturopaths
Shortage Designation (optional)	Primary Care HPSA Mental Health HPSA Dental Health HPSA Medically Underserved Area (MUA) Not Applicable
Rural Designation (optional)	OMB County-Based Designation (Metro/Non-Metro) Core Based Statistical Area (CBSA) /Metropolitan Statistical Area (MSA) Not Applicable
Additional Features (optional)	Major Highways Major Cities
Other data layer (optional)
Add a Title for your Map (optional)
Add a Subtitle (up to 150 characters) (optional)
Add your logo (.jpg only) (optional)
Upload your data (csv or xls only) (optional)
Comments
Terms & Conditions*	I have read and agree to the Terms and Conditions (pdf)
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