ePOC Registration

Name of Facility:

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* 1. Name of Facility:

Facility Phone Number:

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* 2. Facility Phone Number:

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

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

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

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

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

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

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

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

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

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

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

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

Email Address of third person designated:

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* 9. Email Address of third person designated:

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

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

Email Address of fourth person designated:

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* 11. Email Address of fourth person designated:

All designated EPOC staff have reviewed:

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* 12. All designated EPOC staff have reviewed:

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

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

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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* 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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