Maryland Long-Term Care Ombudsman Program Form - Department Of Aging Page 2
Download a blank fillable Maryland Long-Term Care Ombudsman Program Form - Department Of Aging in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Maryland Long-Term Care Ombudsman Program Form - Department Of Aging with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Have you or an immediate family member been a resident of a long‐term care facility or CCRC?
Are you or your immediate family member currently a resident of a long‐term care facility or
CCRC?
Yes_______ No_______
If yes, please explain:
Type of Relationship/Your Role
Facility Name & Location
Dates of Stay
4) Statement of Other Professional Roles within the Host Agency, State or Federal
Government, or Long‐Term Care Facilities including Case Management Services
Do you or an immediate family member have other professional roles within the host agency,
federal or state government or long‐term care facilities? These roles could include employment
other than ombudsman work, serving on a governing or advisory board, serving on ethics
committees, volunteering for another program, managing programs other than ombudsman
programs, etc. Please explain in the space provided.
Yes_______ No_______
If yes, please explain:
Type of Relationship/Your Role
Agency/Entity/Site
Dates
5) Statement of Work as a Guardian, Conservator, Power of Attorney, or Surrogate Decision
Maker
Do you or an immediate family member act as a guardian, conservator, power of attorney, or
surrogate decision maker for a long‐term care resident?
Yes_______ No_______
If yes, please explain:
Type of Relationship/Your Role
Name of Individual Served
Facility
6) Statement of Direct Involvement in the Licensing or Certification of a Long‐Term Care
Facility
Are you or an immediate family member directly involved in the licensing or certification of a
long‐term care facility?
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Tlr 1 - Trustline Registry In-home/license Exempt Child Care Provider Program California Department Of Social Services Background Check Application
Legal
Form 1099-ltc - Long-term Care And Accelerated Death Benefits - Department Of The Treasury - 2013
Financial
Form Ccauth - Authorization Form For John Hancock To Accept Credit Card Payments For Long Term Care Insurance
Business
Related Categories
Parent category: Legal