Additional Nursing Home Applications & Forms
- Applications and Forms
- Gold Seal Application
- Transfer and Discharge Forms
-
Transfer Discharge Notice
[
112.9 kB
]
-
Transfer Discharge Fair Hearing Request
[
134.7 kB
]
-
Transfer Discharge LTC Ombudsman Request
[
179.4 kB
]
-
Spanish Version
[
33 kB
]
-
Spanish Version
[
10.7 kB
]
-
Spanish Version
[
113.3 kB
]
-
Emergency Power Plan Sample Format
[
27 kB
]
(Revised May, 18, 2018) -
Consumer Friendly Summary
[
20.3 kB
]
(Revised May 24, 2018)
Resources
- Mandatory Radon Requirements for 24-hour State Regulated Providers
- Map of Affected Counties for Radon Testing
Miscellaneous Forms
-
Bed Change Request Form
[
83.9 kB
]
-
Bed Change Request Instructions
[
201.2 kB
]
-
Bed Change Room List Form
[
167.9 kB
]
-
Emergency Management Planning
[
52.7 kB
]
-
Fire Incident Reporting and System Failure
[
75.7 kB
]
-
Fire Incident Reporting Form
[
89.2 kB
]
-
Unconditional Guarantee of Payment form
[
9.9 kB
]
-
Staff Calculation Form
[
44.2 kB
]
-
Minimum Hours Reference Sheet
[
29.1 kB
]
Hotline Posters are available online only; please note the smaller version is acceptable regarding surveys.
-
Hotline Poster
[
1010.2 kB
]
(can be printed on 8 1/2" x 14" or 11" x 17") - English
-
Hotline Poster
[
1.5 MB
]
(can be printed on 8 1/2" x 14" or 11" x 17") - Creole
-
Hotline Poster
[
1011.7 kB
]
(can be printed on 8 1/2" x 14" or 11" x 17") - Spanish
-
Hotline Poster
[
1.5 MB
]
(can be printed up to 36" x 48" - special paper/printer required) - English
-
Hotline Poster
[
1.5 MB
]
(can be printed up to 36" x 48" - special paper/printer required) - Creole
-
Hotline Poster
[
1.5 MB
]
(can be printed up to 36" x 48" - special paper/printer required) - Spanish
Consumer Guides
- Nursing Home Guide
- Nursing Home Watchlist
- Guidade Hogares de Ancianos (Spanish Nursing Home Guide)
