AGENCY INFORMATION

Agency Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

CONTACT INFORMATION  (at least 1)

Name

Phone

Email

Owner

Name

Phone

Email

Administrator

Name

Phone

Email

DPCS/Clinical Manager

Name

Phone

Email

Billing Manager

Name

Phone

Email

ADDITIONAL INFORMATION

Medicare Provider ID:

Medicaid Number:

NPI:

Tax ID Number (EID):

Fiscal Intermediary

• NGS
• CIGNA/CGS
• PALMETTO
• NHIC

Accrediting Body (Survey)

• Joint Commission
• CHAP
• State
• ACHC

FI Submitter ID:

FI PAYOR ID/CONTRACT ID:

Average Daily Census:

Medicare Work Week:

• SUN-SAT
• MON-SUN

Current EMR Software:

NOTES/COMMENTS

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