License Request Form

RUG-III Analyzer License Request Form

Facility Name*

Address

If you want the software delivered to you on a CD-ROM, type in the address to which you want the disk to be mailed.

Facility State*

FAC_ID*

The FAC_ID is printed on your facility's CMS Initial Feedback and Final Validation Reports. Ask the MDS Coordinator at the facility to copy the first page of either of these reports and attach it to this form if you have any doubts about FAC_ID. RUG-III Analyzer will not work at your facility if this field is not correct.

Facility Phone*

Facility Email*

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Facility Contact*

Choose the size of your facility

Facility Size (number of licensed beds)

<50

51-75

76-100

101-150

151-200

201-250

251-300

>301

* Indicates a required field.