Ohio KēPRO :: Provider Update Form

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Ohio KePRO Provider Update Form

To assist us in keeping accurate records on your facility and to ensure communications are directed to the appropriate individuals, please complete this form and return to Ohio KePRO by either fax or e-mail.

Please indicate type of provider:

Acute Care (PPS) Hospital
Critical Access Hospital
Home Health Care Agency
Long Term Acute Care Hospital
Comprehensive Outpatient Rehabilitation facility (CORF)

Managed Care Organization
Rehabilitation Facility
Skilled Nursing Facility
Nursing Home
Hospice Facility

Medicare Provider Number:

Provider Name:

Provider Address:

City, State and Zip:

Provider Website:

Provider Main Phone:

Provider Main Fax:

President/CEO Contact Name:

President/CEO Contact Title:

Telephone:

E-mail:

Fax:

Other:

QIO Liaison Name:

QIO Liaison Title:

Telephone:

E-mail:

Fax:

Other:

Compliance Officer Name:

Compliance Officer Title:

Telephone:

E-mail:

Fax:

Other:

Medical Records Contact Name:

Medical Records Contact Title:

Telephone:

E-mail:

Fax:

Other:

Quality Improvement Contact Name:

Quality Improvement Contact Title:

Telephone:

E-mail:

Fax:

Other:

Are there any other individuals at your facility that you would like us to have contact information for?
If yes, please provide us with their information below:

Type of Contact:

Name:

Title:

Telephone:

E-mail:

Fax:

Other:

Type of Contact:

Name:

Title:

Telephone:

E-mail:

Fax:

Other:

Form Completed By:

Your Email Address:

Thank you for providing us with this valuable information.
Please return this form to:

Ohio KePRO
5700 Lombardo Center Drive
Rock Run Center, Suite 100
Seven Hills, Ohio 44131

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