Form Cms-671 - Ltc Facility Application For Medicare/medicaid

Download a blank fillable Form Cms-671 - Ltc Facility Application For Medicare/medicaid 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-671 - Ltc Facility Application For Medicare/medicaid 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

■■ ■■ ■■
■■ ■■ ■■
■■ ■■ ■■
■■ ■■ ■■
■■ ■■ ■■
■■
■
■
■■■■■■■
■■
■
■
■■■
■■■
■■■
■■■
■■■
■■■
■■■
■■■
■■■
■
■
■
■
■
■
■
■
■■ ■■ ■■
■■ ■■ ■■
■
■
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
LONG TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID
Standard Survey
Extended Survey
■■ ■■ ■■
■■ ■■ ■■
■■ ■■ ■■
■■ ■■ ■■
From: F1
To: F2
From: F3
To: F4
MM
DD YY
MM
DD YY
MM
DD YY
MM
DD YY
Name of Facility
Fiscal Year Ending: F5
Provider Number
■■ ■■ ■■
MM
DD YY
Street Address
City
County
State
Zip Code
Telephone Number: F6
State/County Code: F7
State/Region Code: F8
■■
A. F9
01 Skilled Nursing Facility (SNF) - Medicare Participation
02 Nursing Facility (NF) - Medicaid Participation
03 SNF/NF - Medicare/Medicaid
■
■
B. Is this facility hospital based? F10 Yes
No
■■■■■■■
If yes, indicate Hospital Provider Number: F11
■■
Ownership: F12
For Profit
NonProfit
Government
01 Individual
04 Church Related
07 State
10 City/County
02 Partnership
05 Nonprofit Corporation
08 County
11 Hospital District
03 Corporation
06 Other Nonprofit
09 City
12 Federal
■
■
Owned or leased by Multi-Facility Organization: F13 Yes
No
Name of Multi-Facility Organization: F14
Dedicated Special Care Units (show number of beds for all that apply)
■■■
■■■
F15
AIDS
F16
Alzheimer's Disease
■■■
■■■
F17
Dialysis
F18
Disabled Children/Young Adults
■■■
■■■
F19
Head Trauma
F20
Hospice
■■■
■■■
F21
Huntington's Disease
F22
Ventilator/Respiratory Care
■■■
F23
Other Specialized Rehabilitation
■
■
Does the facility currently have an organized residents group?
F24
Yes
No
■
■
Does the facility currently have an organized group of family members of residents?
F25
Yes
No
■
■
Does the facility conduct experimental research?
F26
Yes
No
■
■
Is the facility part of a continuing care retirement community (CCRC)?
F27
Yes
No
If the facility currently has a staffing waiver, indicate the type(s) of waiver(s) by writing in the date(s) of last approval. Indicate the
number of hours waived for each type of waiver granted. If the facility does not have a waiver, write NA in the blanks.
■■ ■■ ■■
Waiver of seven day RN requirement.
Date: F28
Hours waived per week: F29________
■■ ■■ ■
■
Waiver of 24 hr licensed nursing requirement.
Date: F30
Hours waived per week: F31________
MM
DD YY
Does the facility currently have an approved Nurse Aide Training
■
■
and Competency Evaluation Program?
F32
Yes
No
Form CMS-671 (12/02)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 51a401 - Governmental Public Facility Application For Sales Tax Rebate - 2010 Form 51a401 - Governmental Public Facility Application For Sales Tax Rebate - 2010 Financial
Form 51a401 - Governmental Public Facility Application For Sales Tax Rebate Form 51a401 - Governmental Public Facility Application For Sales Tax Rebate Financial
Form Cms-r-0235a - Data Use Agreement (dua) Addendum For Data Acquired From The Centers For Medicare & Medicaid Services (cms) 2012 Form Cms-r-0235a - Data Use Agreement (dua) Addendum For Data Acquired From The Centers For Medicare & Medicaid Services (cms) 2012 Legal
Form Cms-10252 - Data Use Agreement (dua) Certificate Of Disposition (cod) For Data Acquired From The Centers For Medicare & Medicaid Services (cms) Form Cms-10252 - Data Use Agreement (dua) Certificate Of Disposition (cod) For Data Acquired From The Centers For Medicare & Medicaid Services (cms) Medical
Form Cms-r-0235 - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Data Containing Individual Identifiers Form Cms-r-0235 - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Data Containing Individual Identifiers Medical
Form Cms-r-0235u - Data Use Agreement (dua)- Update To Existing Dua - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Data Form Cms-r-0235u - Data Use Agreement (dua)- Update To Existing Dua - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Data Medical
Form Cms-r-0235l - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Limited Data Sets Form Cms-r-0235l - Agreement For Use Of Centers For Medicare & Medicaid Services (cms) Limited Data Sets Medical
Cms-1539 - Centers For Medicare & Medicaid Services Cms-1539 - Centers For Medicare & Medicaid Services Medical
Form Cms-20014 - Notice Of Exclusions From Medicare Benefits - Skilled Nursing Facility (nemb-snf) Form Cms-20014 - Notice Of Exclusions From Medicare Benefits - Skilled Nursing Facility (nemb-snf) Medical
Form Cms-1563 - Monthly Intermediary Report On Medicare Secondary Payer Savings Form Cms-1563 - Monthly Intermediary Report On Medicare Secondary Payer Savings Medical

Related Categories

Parent category: Medical
Download
Go
Page of 6