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MDS/OASIS Email Registration

Florida Provider Email Alert Registration

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* 1. Individual Name:

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* 2. Facility Name:

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* 3. Facility ID:

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* 4. Provider ID (CMS Certification Number):

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* 5. User Type:

Individual/Facility

Corporate/Facility

Third Party/Consultant

Vendor

Other (please specify)

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* 6. Phone Number:

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* 7. Fax Number:

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* 8. Email Address:

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* 9. Provider Type

ePOC

MDS

OASIS

Swing Bed

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* 10. Action:

Opt-In

Opt-Out