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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 time
Calendar
Today
First name:
Last Name:
E-mail:
Phone Number:
(
)
-
Second three digits
Last 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: