If you are contracted for our referral service, please fill out your updates below.

If you are not a member of California Registry's facility referral service -
Apply Now

 

Facility Name: 
Facility Street Address: 
City, State and Zip:
Tel Number:   (555-555-1212)
Fax Number: (555-555-1212)

Your Name:  
Email Address: 
Website Address:

ROOM RATES: (starting rates)
Shared Room $ Private Room $
Do you accept hospice referrals? NoYes  - Rate per day:
Do you accept respite referrals?   NoYes  - Rate per day:
Will you accept SSI as total payment (no family supplement)? Yes No

Please list your vacancies below: