ePOC Registration

* 1. Name of Facility:

* 2. Facility Phone Number:

* 3. Provider ID (CMS Certification Number).   Call the Florida QIES Helpdesk at 850-412-4501 if unknown:

* 4. Name of first designated person receiving required account logins and passwords for ePOC enrollment (At least two must be indicated):

* 5. Email Address of first person designated (At least two must be indicated):

* 6. Name of second designated person receiving required account logins and passwords for ePOC enrollment (At least two must be indicated):

* 7. Email Address of second person designated (At least two must be indicated):

* 8. Name of third designated person receiving required account logins and passwords for ePOC enrollment:

* 9. Email Address of third person designated:

* 10. Name of fourth designated person receiving required account logins and passwords for ePOC enrollment:

* 11. Email Address of fourth person designated:

* 12. All designated EPOC staff have reviewed:

* 13. Questions or Comments (List training requests or specifics problems you have or anticipate related with ePOC implementation):

* 14. I attest that my facility is ready for EPOC activation aware that all User ID’s have to be maintained with up-to-date current staff information and passwords have to be changed every 60 days:

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