FACILITY EMAIL CHANGE REQUEST HEALTH CLAIMS FOR AUTO INSURANCE

NAME OF FACILITY ADDRESSFACILITY LOCATION PROC
COMPANY LOG NAME OF FACILITY ADDRESS OF FACILITY
CONTRACT OPERATOR FACILITY LIST OHIO ENVIRONMENTAL PROTECTION

FACILITY EMPLOYEE [CCR TITLE 23 SECTION 2715(F)]
(FACILITY NAME) EMERGENCY OPERATIONS PLAN ANNEX C EVACUATION ATTACHMENT
(FACILITY NAME) EMERGENCY OPERATIONS PLAN ANNEX E SHELTER IN

FACILITY EMAIL CHANGE REQUEST HEALTH CLAIMS FOR AUTO INSURANCE


Facility Email Change Request

Health Claims for Auto Insurance Processing

2235 Sheppard Avenue East, Atria II. Suite 600

Toronto, Ontario

M2J 5B5

[email protected] Fax.: 416 497 6505



1.1.1.1.1.1.1.1


240 Duncan Mill Road, Suite 800, Toronto, Ontario, Canada M3B 1Z4

Tel.: (416) 445-5912 Fax.: (416) 445-8383



Read this BEFORE you submit this form. This form is required if the following conditions apply:


  1. No user in the practice has access to the Facility Administration tab in HCAI (shown below)

    • As long as there is a user administrator in the practice who can access the Facility Administration tab (shown below) the Authorizing Officer’s email can be changed internally.

  2. The Authorizing Officer’s email address is incorrect; therefore password reset emails are not arriving to the Authorizing Officer



FACILITY EMAIL CHANGE REQUEST HEALTH CLAIMS FOR AUTO INSURANCE



Please follow these instructions:


  1. If you are completing the form by hand, PRINT clearly and complete all information in full.


  1. Return the completed form by courier or FAX 416-497 6505, attn: HCAI Processing.



Existing Information ( * = mandatory field)

*Facility Name (as registered)      

HCAI Facility Number (if available)      

*Address:      

*Name of Authorizing Officer      

*Old Email Address:      


New Authorizing Officer Email Information


*Correct/new Email Address      

Is password reset for AO required? _____Yes _____No


Owner/Authorizing Officer (AO) Information


Name:      

Phone:      


AO Signature: ___________________________________


Date:      

103182.doc


(NAME OF FACILITY) C HILD CARE EMERGENCY BASIC EMERGENCY
(NAME OF FACILITY) C HILD CARE EMERGENCY CHECKLISTS DATE
0510 SECTION 22 12 16 FACILITY ELEVATED POTABLEWATER STORAGE


Tags: change request, change, request, claims, insurance, email, facility, health