emergency closure notification form


Please use this form to notify the Network of an emergency event that has affected your facility (i.e. power failure, storm damage, etc.)  If your facility is closed or you are re-routing patients for treatment, please advise.
   
Today
   
   
   
 
( )-
   
 
(6-digits)
 
 
 
Current Facility Operating Schedule:  


 
Current Status of Patients: