Better Health Care for All Floridians
Facility Quality Assessment User Registration Form
User ID:
*
*User ID Required
*6 - 10 Characters
*Please select one
*Please select one
Provider Type:
*
Please select:
Intermediate Care Facility
Nursing Home
*Please select one
Facility Name:
*
*Plesae select one
First Name:
*
*Name Required
*Invalid Format
Last Name:
*
*Name Required
*Invalid Format
Phone:
*
*Phone # Required
(555) 555-5555
Email:
*
* Email Required
*Invalid Format
Password Recovery Question 1:
*
Please select:
What Is The Last Name Of Your Best Friend?
What Is Your Favorite Movie?
What Town Were You Born In?
What Was The Name Of Your First Pet?
What Was The Name Of Your High School?
*Please select one
Security Answer 1:
*
*Required
Password Recovery Question 2:
*
*Please select one
Security Answer 2:
*
*Required
Password:
*
*Required
*Must be 6-15 long
Verify Password:
*
*Required
*Not Match
Note:
After clicking the Submit button, if you registered successfully, you will be directed to the registration results page. You will be required to print out the user agreement form, fill it out, sign it and mail it or fax it in to the address given.