emergency closure notification form

Please use this form to notify the Network of an emergency event that has affected your facility (i.e. power failure, storm damage, etc.) If your facility is closed or you are re-routing patients for treatment, please advise.

Date of Initial Event:	Date and timeToday
First name:
Last Name:
E-mail:
Phone Number:	( )- Second three digitsLast four digits

Provider Number:	(6-digits)
Facility Name:
Total Patient Census:

Current Facility Operating Schedule:	Open Closed Altered
Briefly describe event causing change to operations/closure:
Current Status of Patients:	Re-routed to alternate facility Re-scheduled for alternate date
Additional Information: