Facility information:
Facility Name
Name is required
CMS Certification Number (CCN) / Hospital ID (optional)
Strongly recommended if applicable
Type of facility
Please select all that apply
You must select at least one facility type
This facility accepts Medicaid
Make sure to provide the facility CCN
This facility provides the majority of services for low fee or no fee.
Is this facility part of a local or regional health system, either public or private?