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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Contact us:       Phone: (419) 309-2053       Email: info@prosolhme.com
​or use the Organization Information Form below:
Fitter
HME / DME
Medical Supplies
Rehab Technology
Clinical Respiratory
Hospice
Home Health