Facility Questionnaire » RevSuite Solutions

Please enable JavaScript in your browser to complete this form.

Company Name

Legal Name (If Different)

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you use Point Click Care

Yes
No

If "Yes", enter PCC Organization Code (PCC login Prefix)

Region and Facility Information

Region Name (If Applicable)

Facility Name

Facility Address

Address Line 1

Address Line 2

City

State

Zip Code

Facility Workstation Name (Create a unique name or identifier for each facility, e.g., street name, etc.)

Facility Primary Contact Information

Name

First

Last

Phone

Phone Extension

Fax Number

Email

Medicaid State Regulations

Personal Needs Allowance

Daily Rate

QIT Required Threshold

Resident Asset Maximum

Resident with Spouse Asset Maximum

Plan Names (List all Managed Medicaid Plan Names)

Custom Captcha

=