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KEPRO - Beneficiary and Family Centered Quality Improvement Organization (BFCC-QIO)
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Welcome to the Memorandum of Agreement/Provider Update online form.

This form will allow you to submit your organization's MOA and contact information to KEPRO. Please provide the details below.
Fields marked with an asterisk (*) are required. You will not be able to edit this screen once your request is submitted.
When you are finished, click Submit. All information provided will be handled securely by our team.

The individual listed below as the “Authorized Signature” will receive an email from DocuSign after the MOA information has been
processed by KEPRO, which may appear in his/her junk or spam folder. Once this individual signs the MOA through DocuSign, it will
be routed back to KEPRO for a final signature, and the fully executed copy of your organization’s MOA will be emailed via DocuSign.

Please note that there should be no changes made to the MOA document. The wording is mandated and approved by the
Centers for Medicare & Medicaid Services (CMS).

 

Person Completing Form
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Provider Details
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Provider Contacts
CEO/Administrator/Owner Compliance Officer (if applicable)
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QIO Liaison/DON/Facility Contact Medical Record Contact
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Authorized Signature
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