Facility Notification Form

The Facility Notification Form is for our participating providers that are currently in our network. If your facility is interested in joining our network, please complete the Participating Provider Request Form

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Are you adding a location?:

Yes

Select this option when a new clinic/hospital location needs to be added to an existing participating provider.

Are you updating a location?:

Yes

Select this option to update information related to an existing participating facility location. Complete this form for changes to the facility phone or fax number, if the facility is relocating and/or there is an address change.

Are you terming a location?:

Yes

Select this option when a clinic is closing.

New Location

Effective Date*

List in Provider Directory*

Yes

Location Name*

Physical Address*

City*

State*

Zip*

County*

Accepts Mail at this Address*

Yes

Clinic Phone Number*

Clinic Fax*

Clinic Manager Name*

Clinic Manager Phone*

Business Fax*

Clinic Manager Email*

Billing Tax ID*

Billing Contact Name*

Billing Name*

Billing NPI#*

Billing Address*

Billing City*

Billing State*

Billing Zip*

Billing Phone*

Billing Fax*

Billing Email*

Do you use electronic medical records (EMR), is it certified by an Office of the National Coordinator for Health Information Technology Authorized Testing and Certification Body (ONC-ATCB)?*

Yes

Please list the name of the EMR system your organization uses.*

Rural Health Clinic*

Yes

Swing Bed Facility*

Yes

Total Number of Beds:

Number of Certified Medicare Beds:

Number of ICU/CCU Beds:

Facility is enrolled in Medicare?*

Yes

Medicare ID*

Medicare Enrollment Date*

Essential Community Provider Type

Federally Qualified Health Center Provider

Indian Health Provider

Family Planning Provider

Ryan White Provider

Hospital Provider

Other ECP Provider

Facility Website/Digital Contact:

On Call/After Hours/Extended Hours*

Yes

Languages spoken by staff at this facility: *

Do you use Interpreters to handle requests in a language not familiar to anyone on your staff?*

Yes

Do you use a Language Line to handle request in a language not familiar to anyone on your staff?*

Yes

Is the exterior of your facility location/building accessible for people with physical disabilities?*

Yes

Is the interior of your facility/office accessible for people with physical disabilities?*

Yes

Are your exam rooms accessible for people with physical disabilities?*

Yes

Does your office have equipment to accommodate for people with physical disabilities?*

Yes

Does your office have restrooms to accommodate for people with physical disabilities?*

Yes

Does your facility use restraint measures such as restraints or seclusion?*

Yes

Do you have a policy to support the use of restrictive measures?*

Yes

If you do not use restrictive measures, do you have a policy to support your patient’s right to be free from any form of restraint or seclusion?*

Yes

Accreditation Types:*

The Joint Commission Accreditation:

Yes

Joint Commission Number:

Det Norske Veritas Healthcare:

Yes

Det Norske Veritas Number.:

Healthcare Facilities Accreditation Program:

Yes

Healthcare Facilities Number:

Accreditation Association Ambulatory Healthcare:

Yes

Ambulatory Healthcare Number:

Commission Accreditation Rehabiliation Facility:

Yes

Rehabilitation Facility Number:

Facility NPI #s/Taxonomy Codes:*

Facility NPI#	Facility Type	Taxonomy Code	Billing NPI#

Practitioners at this location:*

Practitioner	Practitioner NPI#

Update Location

Facility Name*

Facility NPI*

Effective Date*

Reason for Change*

Old Information*

New Information*

Type of Phone Number Change*

Primary Secondary

Type of Fax Number Change*

Business Referral

Change Request*

Location Name:

Physical Address:

City:

State:

Zip:

County:

Accepts Mail at this Address:

Yes

Clinic Phone Number:

Clinic Fax:

Billing Tax ID*

Billing Contact Name*

Billing Name*

Billing NPI#*

Billing Address*

Billing City*

Billing State*

Billing Zip*

Billing Phone*

Billing Fax*

Billing Email*

Languages spoken by staff at this facility: *

Do you use Interpreters to handle requests in a language not familiar to anyone on your staff?*

Yes

Do you use a Language Line to handle request in a language not familiar to anyone on your staff?*

Yes

Terminate Location

Termination Date*

Terminating Location Name*

Physical Address*

City*

State*

Zip*

Phone*

Tax ID#*

Billing NPI*

Billing Name*

Reason for Termination*

Where are practitioners relocating?

Practitioner Name	New Site	Practitioner NPI#

List site in Wisconsin, or list state if relocating (required by Wisconsin law.)

Practitioners at this location:

Practitioner Name	Practitioner NPI#

Completed By: *

Email: *

Phone: *

*Indicates a required field

Facility Notification Form

New Location

Update Location

Terminate Location

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