CMS Healthcare Facility Notification Form
DO NOT MAIL A COPY OF YOUR PLAN

The CMS Emergency Preparedness Rule establishes national emergency preparedness standards for Medicare- and Medicaid-participating providers and suppliers. This program outlines facility requirements relative to preparedness, response, recovery, for both natural and man-made disasters, while coordinating with federal, state, tribal, regional, local emergency preparedness systems and other healthcare providers.

These requirements are focused on essential elements necessary for maintaining access to healthcare during disasters or emergencies: while safeguarding human resources and maintaining business continuity.

CMS Facilities should complete this submission annually to ensure compliance with facility specific requirements during a CMS survey. Further guidance may be located at the CMS Website.

https://tinyurl.com/CMSEmergencyPrepResources

Email address *
Reporting Year *
Type of Facility *
(nursing home, dialysis, outpatient, supply distribution, call-center, etc.)
Name of Person Completing Form *
Your answer
Title *
Your answer
Contact Number Including Area Code *
Your answer
Facility Name *
Your answer
Parent Company or Organization if applicable
Your answer
Facility Street Address *
Physical location of facility
Your answer
Facility Street Address 2
(Building number, Suite number, etc.)
Your answer
Facility City *
Your answer
Facility State *
Your answer
Facility Zip *
Your answer
Primary Facility Phone Number *
Your answer
Name of Emergency Point of Contact *
Your answer
Emergency POC Contact Number Including area code *
Your answer
Security Point of Contact (if applicable)
Your answer
Security Phone Number including area code
Your answer
Does this Facility have an On-Site Emergency Operations Center?
Type of Building/Structure
(single building, multi-office complex, warehouse, etc.)
Your answer
HAM Radio Capabilities *
Designated HAM Radio Coordinator- Name/Call Sign/Phone Number if applicable
Your answer
Total Number of Beds at the Facility *
if none, enter 0
Your answer
Special Services Available On-Site
Check all that apply:
Primary Medical Supplier
Your answer
Primary Gases Supplier
Your answer
Primary Food Service Supplier
Your answer
Number of Days Food Service On-Site. *
Your answer
Generator On-Site? *
Make and Model of On-Site Generator
Your answer
Generator Repair and Service Vendor
Your answer
Generator Fuel Required
Does this Facility have Temporary Heating/Cooling Units? *
Does this Facility have Back-up Water Supply? *
Number of Full-Time Employees *
if none, enter 0
Your answer
Number of Part-Time Employees *
if none, enter 0
Your answer
Number of Volunteers *
Your answer
Facility Based Ambulance Service *
Number of Facility Owned Vehicles Available for Emergency Evacuation *
if none, enter 0
Your answer
Has an alternative care site been identified?
Name of Alternative Care Site
Your answer
Alternative Facility Point of Contact
Your answer
Does this Facility have a Reunification Plan? *
A copy of your responses will be emailed to the address you provided.
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