Main Contact Email

Facility Name

Parent Organization (Client - if Organization is Larger than One facility)

Required Dashboard User Logins

Please provide a list that consists of FIRST NAME, LAST NAME, and EMAIL ADDRESS of each individual at the facility that will require access to the Care Analytics User Dashboard.

Assessment Email Notifications

Please provided a list of emails that will receive the email notification every time a assessment or Real time comment is completed

Medicare Provider Number

FACILITY REGISTRATION