Form Cms-3070h - Icf/iid Deficiencies Report Page 3
Download a blank fillable Form Cms-3070h - Icf/iid Deficiencies Report 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 Form Cms-3070h - Icf/iid Deficiencies Report 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
3
4DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0062
INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
DEFICIENCIES REPORT
FOR INITIAL OR ANNUAL RECERTIFICATION SURVEY
I certify that I have reviewed the following requirements and conditions for: (a) Full Survey _____, (b) Extended Survey _____,
or (c) Fundamental Survey _______, and unless indicated on this form, the facility was found to be in compliance with the
Standards and the Conditions of Participation.
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
FOR FOLLOW-UP SURVEY
For the purpose of this onsite visit, I certify that I have reviewed each Condition of Participation and related Standard(s) found
not to be in compliance during the survey on ______________, and unless indicated on this form, the facility was found to be
in compliance with the Standards and/or the Conditions of Participation.
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
SIGNATURE
TITLE
DATE
FORM CMS-3070H (03/13)
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cms-2786x - Fire Safety Survey Report - Icf-iid (apartment House) 2012 Life Safety Code
Medical
Form Cms-2786w - Fire Safety Survey Report - Icf-iid (large Facilities) 2012 Life Safety Code
Medical
Related Categories
Parent category: Medical