New Facility Registration
Facility Information
State:
Please enter the date when your facility opened:
When did you treat your first patient?
Please select your facility type:
Medicare CCN/Provider # (if known)
NW3: starting with either “31”, “40”, or “48”
NW4: starting with either “08”, “39”, or “73”
NW5: starting with either “09”, “21”, “49”or “51”
National Provider Identification (NPI) #
Facility Legal Name
Facility Doing Business As (DBA) Name
Phone Number:
Fax Number
General Facility Email
Physical Address 1
Physical Address 2
City
County
Zip Code
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.
No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
Next Step: Operations
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Operation Details
Corporate/Parent Organization
Profit Status
Location Type
Total Number of Stations
Number of Isolation Stations
Number of isolation stations cannot equal or exceed total number of stations
Services Offered (check all that apply)
MWF Shift
Number of Shifts
Facility Open Time
Facility Close Time
TTS Shift
Number of Shifts
Facility Open Time
Facility Close Time
Next Step: Contacts
Previous Page
Facility Contacts
What is the name of your back-up facility?
Name of Facility Manager/Administrator
Email Address for Facility Manager/Administrator
Name of EQRS Contact
Email for EQRS Contact
Name of Facility Director of Nursing
Email Address for Director of Nursing
Name of Facility Medical Director
Email Address for Facility Medical Director
Name of Facility Social Worker
Email Address for Facility Social Worker
Name of Person Completing this Form
Email for Person Completing the Form
Next Step: Submit
Previous Page
Verify you are not a robot and submit your data using the Submit button
at bottom of the form
Submit Data
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.