Click below to download the EIDR request form and sample form for Nursing Home and Adult Day Health Care facilities.
Please submit completed request form for Nursing Home and Adult Day Health Care facilities to Mary Mason via email at firstname.lastname@example.org . Contact Mary with questions or requests for information at (225) 342-6116.
For EIDRs for ICF/IIDs, contact Enrika Lacour at email@example.com or (318) 487-5006..
For EIDRs for Hospitals, Hospital Based Rural Health Clinics, Free Standing Psych and Hospital Distinct Part Psych, contact Tizi Robinson at firstname.lastname@example.org or (225) 219-4285.