Add/Update Survey Report System Notification Information

The ISDH Survey Report System will send an email to the email address provided by health care facility.  The ISDH highly recommends that each facility identify an email address that is assigned to the facility rather than one individual.  Please indicate below the facility’s primary email address to which notifications will be sent. A facility may request an additional notification for areas such as the corporate office or owner’s office. Please complete the corporate office or owner’s office Email address if notifications are to be copied to these offices.


Note: The information you submit on this form may be considered public record and subject to disclosure, upon request. **These fields are required.

** Primary Facility Email:
Corporate office or Owners office Email:
** Name of facility:
** Facility ID:

As it appears on the bottom of the CMS Form 2567
Facility Address:
** Name of individual providing information:
** Day telephone #