Get Hea1910

Filling out the Hea1910 form is an essential step for healthcare providers wishing to register for the Volunteer Program in Ohio. This guide will provide you with a clear and straightforward process to ensure your application is completed accurately.

Follow the steps to complete your registration successfully.

1. Click ‘Get Form’ button to access the Hea1910 online registration form, preparing to fill out your information.
2. Begin by indicating the year you are registering for and select whether this is your initial or annual registration.
3. In the 'Director' section, fill out the last name, first name, and middle initial of the individual responsible for the application.
4. Provide the business or facility name, followed by the complete street address, city, state, and ZIP code.
5. Enter the county in which your facility is located, along with the area code and telephone number. Include the area code and fax number if available.
6. Input your Federal tax ID number and nonprofit tax ID number as applicable.
7. Indicate your funding source by selecting one of the options provided, or explain if it is something different.
8. Answer whether you have a quality assurance program in place by selecting yes or no.
9. Select if your facility provides 24-hour services with a yes or no response.
10. Indicate if your facility has shelter or living quarters attached by selecting yes or no.
11. Specify the types of services your facility provides by selecting the appropriate options. If necessary, provide explanations for other service types.
12. Review your filled-out form carefully to ensure all information is accurate and complete.
13. Affix the signature of the authorized agent in the designated area and include the date of signing.
14. Once everything is finalized, save your changes, download a copy of the form, print it for your records, or share it as necessary.

Completing the Hea1910 form online is straightforward. Start your registration process today!