Facility Profile

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Facility Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Person Name

First

Last

Position

Phone Number

Facility Capacity (Number of Beds / Residents)

Single / Individual Rooms Available

Number of Shared Rooms Available

Average cost of Single Room

Average Cost of shared Room

Do you accept waivers, (Source and CCSP) Clients

If Yes, Do you also accept clients with pending applications

Do you accept Hopsice patients

If yes, On what terms

Additional info / please tell us more about your company

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