WHA Information Center New Facility Form

Please complete this form in its entirety. This form is used by WHAIC to set-up your facility in our database and to communicate with you for your required state reporting.

A 3-digit facility ID number will be assigned and emailed to the person completing the form, the administrator/CEO (if different), and primary contact(s). We ask that you use your assigned 3-digit facility ID to communicate with us, to register for the secured portal, and must be used on your 837 discharge data files.

Fields marked with an *asterisk* are required, although we would appreciate the entire form completed to allow for more efficiencies and timeliness in our communications with further instructions. For more information about WHAIC, please see our website.

(Data entered within this form is neither stored nor shared outside of WHAIC)

Facility Information:

*Name of person submitting form:

*Email Address:

*Facility Official Name/DBA:
*Open Date:

*NPI Billing Number:
*Administrator/CEO Name:
*Admin/CEO Email*:


Zip Code:

Hospital Fiscal Year:

Contact Information:

Facilities may have as many contacts as they wish; however, each contact (including those below) must register to the secured portal. The information we collect on this form allows WHAIC to identify specific person(s) to contact to initiate the data submission process and Annual Survey submission process.

Primary WHAIC Data Contact (main source of communication and overall responsibility for discharge data submission) that will register to the Secured Portal upon receipt of the facility ID (Click here for Roles Document):
*Email Address*:


Facility Accounting Information:
CFO Name:

CFO Email:

Accounting Mgr. Name:
Accounting Mgr. Email:

All WIpop users and Annual Survey submitters must register to our portal and primary contact is copied on all registrations.

Vendor Information:
*EMR/Billing Vendor Name:

Vendor Tech Support Contact: