Facility Information Facility Name (Doing Business As), if different: Provider ID Effective Date of Change in Provider ID Facility Street Address Facility City, State, ZIP Code New Change in Form Type of Change Change of Ownership Change in Rate Notification Contact MA Corp (Chap 156) Partnership / LLP Non MA Corp MA Corp (Chap 156 with 501c(3) exemption Legal Status Sole Proprietorship Other For-Profit MA Non-Profit Corp (Chap 180) Governmental Entity Other Non-Profit Limited Liability Corporation (LLC) Federal Employer Identification Number (FEIN) Please complete the section below with the name, title, mailing address, phone number and email address of the person designated by the facility to receive rate reimbursement notifications. Rate Contact Information Contact Name Contact Title Mailing Street Address Mailing City, State, ZIP Code Contact Phone Number Contact E-mail Address Signature of Preparer Date Print Name of Preparer Title
Facility Information Facility Name (Doing Business As), if different: Provider ID Effective Date of Change in Provider ID Facility Street Address Facility City, State, ZIP Code Type of Change New Change of Ownership Change in Form Change in Rate Notification Contact Legal Status MA Corp (Chap 156) MA Corp (Chap 156 with 501c(3) exemption MA Non-Profit Corp (Chap 180) Limited Liability Corporation (LLC) Partnership / LLP Sole Proprietorship Governmental Entity Non MA Corp Other For-Profit Other Non-Profit Federal Employer Identification Number (FEIN) Please complete the section below with the name, title, mailing address, phone number and email address of the person designated by the facility to receive rate reimbursement notifications. Rate Contact Information Contact Name Contact Title Mailing Street Address Mailing City, State, ZIP Code Contact Phone Number Contact E-mail Address Signature of Preparer Date Print Name of Preparer Title
Nursing-Facility-General-Contact-Info.docx