COVID Relief Facility Capacity Change Request for Assistance

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* 1. Facility Information

Facility Name:

NPI:

CCN:

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* 2. Point of Contact Information:

Applicant Name:

Applicant Email:

Applicant Phone Number:

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* 3. I would like to receive guidance or technical assistance from the IPRAT team

Onsite Infection Prevention visit

Onsite Education visit

CRF related guidance

COVID-19 related guidance

Other (please specify)

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* 4. Please provide any additional details you would like to provide related to your COVID Relief Facility inquiry

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* 5. MDHHS retains discretionary rights to consider additional information and the right to approve or deny any capacity change requests

Signature of Applicant:

Title/Position:

Date: