1. Organization
1a. Organization Name:	1b. Medicare Provider Number:
1c. Mailing Address 1:	1d. Mailing Address 2:
1e. City:	1f. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	1g. Zip Code: (xxxxx-xxxx)
1h. Telephone:     Ext.	Fax: (xxx-xxx-xxxx)	1i. Website:
2. Contact Person
2a. First Name:	2a. Middle Initial:	2a. Last Name:
2b. Title:	2c. Degree (e.g., RN, MD, PhD):
2d. Mailing Address 1:	2e. Mailing Address 2:
2f. City:	2g. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	2h. Zip Code: (xxxxx-xxxx)
2i. Telephone:     Ext.	Fax: (xxx-xxx-xxxx)	2j. E-Mail:
3. Survey Vendor Organization This section is to be completed for hospitals using survey vendor to conduct the survey.
3a. Organization Name:
3b. Contact Person:
First Name:	Middle Initial:	Last Name:
3c. Title:	3d. Degree (e.g., RN, MD, PhD):
3e. Mailing Address 1:	3f. Mailing Address 2:
3g. City:	3h. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	3i. Zip Code: (xxxxx-xxxx)
3j. Telephone:   Ext.	Fax: (xxx-xxx-xxxx)	3k. E-Mail:

Do you currently have hospitals applicable to this discrepancy report? YesNo

1. Description of the discrepancy, how it was discovered, and the timeframe affected by the issue:

2. Number of eligible discharges affected by the discrepancy and the current number of surveys administered each month (by hospital if applicable):

3. Provide corrective action to fix the discrepancy (including timeframes):

4. Please add any additional information that would be helpful to understand the discrepancy that have not been included above: