Cms-10243

Provider Profile Screen:

(To be completed one time for each CARE provider*)

1. Provider Name

2. Physical Address of Provider

a. Street Address

b. Street Address 2 (optional)

c. City

d. State

e. Zip

3. Provider Identification Numbers

a. Provider NPI

b. CMS Certification Number (also called OSCAR Number or Medicare Provider’s
Identification Number)

4. Provider Type

Choose One:  Acute Hospital  LTCH  IRF  SNF  HHA

5. Activate the ability of other authorized providers to view patient information
collected while at your site?  YES  NO

* This information must be completed by a CARE coordinator and must be completed the first time a coordinator accesses the CARE application. This information may be updated at any time by a coordinator for the provider.