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Office of Health Assurance and Licensing - EIDC User Account Request
The following information is required to obtain secure access to Health Care Provider Online Business Processing - Enhanced Information Dissemination & Collection (EIDC). By submitting this request, you swear or affirm that you are authorized to perform business processes for the facilities listed below.
First Name:
*
Last Name:
*
Title:
*
e-mail Address:
*
Secondary Contact Name:
Reason for request (at least one reason is required):
*
New Account
Add Facilities
Update E-mail Address
Reset Password
Technical Issue
Technical Issue Description:
*
Please identify the type of facility with which you are affiliated (at least one type is required):
*
(To enter multiple entities separate them by comma ",". e.g. 1234N,5678N,0123N)
Long-term Care - Nursing Home (NH)
Enter State ID or Medicare ID:
(e.g. 1234N or 36XXXX))
Long-term Care - Residential Care Facility (RCF)
Enter State ID or Medicare ID:
(e.g. 1234R or 36XXXX)
Non Long-term Care - Health Care Facility (HCF)
Enter State ID or Medicare ID:
(e.g. 0123AS or 01234DC or 36XXXX)
Non Long-term Care - Hospice
Enter State ID or Medicare ID:
(e.g. 0123HSP or 36XXXX)
Non Long-term Care - Home Health Agency
Enter FAC ID or Medicare ID:
(e.g. OHXXXX OR 36XXXX)
Hospital
Enter Hospital Number:
(e.g. 1111,1112,1113)
NATCEP
Enter Program Number:
(e.g. 365XXXX)
I swear or affirm that the information provided herein, and any attachments hereto, have been prepared or carefully reviewed by me and constitute a truthful and correct disclosure of all information herein. I certify that the undersigned is the operator (if the operator is an individual), the president or other officer (if the operator is a corporation), a partner (if the operator is a partner), or an authorized agent of the operator.
ODH CONTACT INFORMATION
If you have a question regarding use of this form e-mail us at liccert@odh.ohio.gov.
* = Required field
Enhanced Information Dissemination Version 3.0
Software release on: 07/28/2016