Change in Facility Information

Change in Facility Information

Use for Personnel Name Changes, Report Distribution, Unit Name Changes, etc
DO NOT USE THIS FORM FOR FACILITY NAME CHANGE
PLEASE NOTIFY YOUR MANAGER OR THE CORPORATE OFFICE.
IN MANY CASES A NEW CONTRACT MAY NEED TO BE GENERATED
BEFORE CHANGE NAME CAN TAKE PLACE.

Information on this form will be sent to Operations, EPIC, and Managers
Did you check the Facility Profile in HG+ to see what additional information may be missing? Someone else may have already requested a change.
- Medical Director
- Pharmacy Provider
- Quarterly Meetings Period
- Visiting Schedule Changes
- PRIMARY FACILITY FAX NUMBER
Date Created

MonthDayYearHourMinutesAM/PM Option
FACILITY:*
Give as much info on name as possible - Several Facilities have similar names;
If providing a personnel change:
- Is the person replacing someone else?
- Is their Title Changing?
- Check your Condensed Facility Profile Sheet.
- Are they being added to the distribution list?
- Email address if necessary
CHANGES:
Spelling is Important - First and Last names are required
We have added the ability to Upload any Attachments.

Browse Files
Emails can be sent as attachments if you use the Save As Option. Cancelof
Effective Date for Change:

MonthDayYear
Email of Person Submitting*
Should be your Corporate EMAIL Address
Should be Empty: