Nursing Facility Templates

This document is an addendum to the Provider Application and Agreement for Nursing Facility Ventilator Dependent Care (VDC) Services in Mississippi.

This type of document is used to authorize the photographing or recording of a resident in a nursing or assisted living facility. It is specific to the State Long-Term Care Ombudsman Program in Texas.

This form is used for nursing facilities in Pennsylvania to report information related to the Omnibus Budget Reconciliation Act (OBRA). It ensures compliance with OBRA regulations and allows facilities to submit necessary documentation.

This document is used for applying for a license to operate a nursing facility in the state of South Dakota.

This form is used for reporting the quarterly ventilator program data for nursing facilities in Ohio. It is used to track and monitor the usage of ventilators in these facilities.

This form is used for requesting participation in the Ohio Death with Dignity Nursing Facility Ventilator Program.

This Form is used for designating a Long-Term Care Ombudsman as a representative and requesting to appeal a nursing facility discharge in Texas.

This form is used for nursing facilities in Kansas to enter into an agreement with a provider.

This Form is used for consenting to release information and/or appointing an authorized representative for nursing facility care in Oklahoma.

This form is used for notifying the relevant authorities about a patient in a nursing facility in Oklahoma.

This form is used for requesting placement in a nursing facility outside of Washington, D.C. for individuals who require specialized care that cannot be provided in the local area.

This document is used for establishing a legal agreement between a beneficiary and a nursing facility in Washington, D.C. It outlines the terms and conditions of the placement and the responsibilities of both parties.

This form is used for requesting an Independent Informal Dispute Resolution (IIDR) for nursing facilities in Texas.

This Form is used for requesting nursing facility rates in the state of Alabama.

This form is used for determining the medical necessity for wheelchair purchase for clients in nursing facilities in Washington state. It helps determine if a patient requires a wheelchair and if it should be covered by insurance.

This document highlights the flexibilities provided by CMS (Centers for Medicare & Medicaid Services) to long-term care facilities, such as skilled nursing facilities and nursing facilities, in their fight against COVID-19. It includes various measures and guidelines to help these facilities manage and mitigate the impact of the pandemic.

This form is used for referring patients in nursing facilities for MDS 3.0 Section Q assessments in the state of Louisiana.

This document is used to apply for a nursing home in Ohio and indicates that the applicant is ready to proceed.

This form is used for requesting a change in the licensed bed capacity of a nursing facility in Rhode Island.

This document is used for notifying the Oregon Department of Human Services/Oregon Health Authority about nursing facility residents who have chosen hospice care.

This Form is used for participants of the Money Follows the Person (MFP) program in Wisconsin to report their information.

This document is used to determine the period of ineligibility for nursing facility level-of-care in California. It helps assess the level of care needed for individuals and determines the duration of ineligibility for nursing facility services.