Organization Information Form
Call us at: (419) 309-2053
Concern ~ Focus ~ Purpose
By providing us with the following information, you will be helping us to better determine what type(s) of home health consulting services your organization may require. Please feel free to complete any and all portions of this form. There are no "Required" fields. The more information you provide, the faster we will be able to discuss with you the specifics of any consultation arrangement necessary. There is no obligation and your provided information is kept strictly confidential by Proactive Solutions HME Consulting LLC. We are looking forward to hearing from you and to discovering how we may be of service!
ORGANIZATION NAME
ORGANIZATION TYPE
HOW LONG IN BUSINESS?
TOTAL # OF LOCATIONS
MAIN LOCATION STATE
# OF STAFF
CONTACT NAME
CONTACT PHONE
CONTACT E-MAIL
SERVICES OFFERED BY
YOUR ORGANIZATION
COMMENTS / QUESTIONS:
THANK YOU!
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Email: info@prosolhme.com
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