"Ltca State Plan Care Services Transfer Form" - Washington, D.C.

Ltca State Plan Care Services Transfer Form is a legal document that was released by the Washington DC Department of Health Care Finance - a government authority operating within Washington, D.C..

Form Details:

  • Released on February 3, 2016;
  • The latest edition currently provided by the Washington DC Department of Health Care Finance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Washington Dc Department of Health Care Finance.

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Download "Ltca State Plan Care Services Transfer Form" - Washington, D.C.

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CARE SERVICES TRANSFER FORM
State Plan
Long Term Care Administration
Department of Health Care Finance
Government of the District of Columbia
Select program type from drop-down
DISCHARGING PROVIDER
#
Care Service(s)
Frequency
Cost
PA#
End of Care Date
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
441 4th Street, NW 9th Floor Washington,
DC 20001
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Date:
CARE SERVICES TRANSFER FORM
State Plan
Long Term Care Administration
Department of Health Care Finance
Government of the District of Columbia
Select program type from drop-down
DISCHARGING PROVIDER
#
Care Service(s)
Frequency
Cost
PA#
End of Care Date
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
441 4th Street, NW 9th Floor Washington,
DC 20001
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Date:
RECEIVING PROVIDER
#
Care Service(s)
Frequency
Cost
PA#
Start of Care Date
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
Select agency from drop-down
Provider Name:
Address:
Provider ID: Phone:
Provider Email:
Select One
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