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For Nursing Homes who feel they are missing an Infection Control Incentive Payment, please fill out the below information so we can reach out to federal health and human services for resolution on your behalf.

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* 1. Facility Name

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* 2. Facility Address

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* 3. Facility City

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* 4. Facility State

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* 5. Facility Zip Code

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* 6. Facility Tax ID Number

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* 7. Contact First Name

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* 8. Contact Last Name

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* 9. Contact Title

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* 10. Company Name

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* 11. Phone Number

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* 12. Email

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