Infection Control Plan - Updated 2023

Infection Control Plan - Updated 2023

Please complete this form to place your order.

Your plan will be delivered via email as quickly as we are able to complete it.

Please use proper capitalization & check all spelling before submitting this form.

Do not use "ALL CAPS" or "all lower-case" when completing the form.

Corrections due to misspellings or inaccurate information may result in additional charges up to $50.

Email delivery of your document can be expected by the end of the next business day.

Printed copies can be purchased for $25 + tax & shipping.

Order Date*

Order Type*

Select

Member Status*

Select

Facility Name*

Your company name (as licensing recognizes you)

ONLY ONE FACILITY PER ORDER

Facility Telephone Number*

Phone

Cell Phone for any questions if different

Phone

Facility Street Address*

Facility City, State, Zip*

Facility Email Address:*

Email to use for delivery if different

Facility Type*

Select

Facility License Number*

Nine digit number - Please include the "0" if it is the first number.

ONLY ONE FACILITY PER ORDER

Administrator:*

PLEASE NAME THE PRIMARY ADMINSTRATOR ONLY

Infection Control Lead (Preventionist)*

The name of who will be responsible for training the staff on Infection control & keeping the plan up to date. Use the administrator name if there is no other designee.

Local Licensing Office (City/Location)*

Please verify before providing this information. Some Licensing Office assignments have recently changed.

Payment & Contact Information

FEE*

Select

Payment Type

Select or enter value

Name of Cardholder (name found on card)*

Card Number*

Expiration Date*

CVC*

3 or 4 digit code on back or corner of the card

Billing Address*

Billing zip code*

Thank you for your order!

DISCLAIMER: Community Care Options is providing this service in an effort to assist licensees in meeting the recently revised requirements. The information contained in our revised Infection Control Plan follows the guidelines described in PIN 23-12-ASC. We assume no responsibility or liability for the absence of any information required by your particular analyst or due to inaccurate information provided to us in this form.

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