CMS Healthcare Facility Notification Form
DO NOT MAIL OR FAX 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 medical facility and healthcare provider requirements relative to preparedness, response, and recovery during disasters.

These requirements are focused on essential elements necessary for maintaining all patients’ access to healthcare services during disasters or emergencies while safeguarding patients and staff.

Healthcare facilities are required to provide basic facility information to Shelby County Emergency Management and Homeland Security. This information must include facility-specific information such as identified points of contact, number of beds, alternative care sites, etc. CMS Facilities should complete this submission annually to ensure compliance with specific requirements during the CMS survey. Incomplete, or inaccurate submissions will not be accepted.

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