Long Term Care Templates

This form is used for long term care facilities in Illinois to notify the appropriate authorities of any changes or updates.

This document is for Illinois nursing facilities and ICF/IID providers of long-term care. It is used to establish an agreement between the facility and the provider.

This form is used for reporting long-term care and accelerated death benefits received during the tax year. It is used by individuals and insurance companies to report these benefits to the IRS.

This form is used for providing additional financial information for long-term care applicants in the state of Illinois.

This document is a description of the volunteer long-term care ombudsman position in the state of Nevada. It provides details about the responsibilities and qualifications of this role to advocate for the rights and well-being of residents living in long-term care facilities.

This form is used for assessing the level of care needed for nursing home facilities in Nevada.

This form is used for referring individuals in New Jersey for an onsite occupational clinical assessment.

This form is used for requesting skilled nursing services in a community setting in Washington. It is part of the pre-admission screening and resident review process.

This document is used for applying for long-term care or waiver in the state of Connecticut.

This Form is used for applying for health coverage for seniors and individuals who require long-term care services in Massachusetts.

This document provides information about the annual disclosure statement that Continuing Care Providers in Kansas are required to provide. It includes details about the services offered, pricing, and other important information.

This document is a survey used in Montana to gather information on the income and expenses related to senior care. It helps in assessing the financial aspects of providing care for senior citizens.

This document is an application form for obtaining a license to operate an assisted living facility in the state of Washington.

This form is used for filing a long-term care claim in the state of Texas. It is used to request reimbursement for expenses related to long-term care services.

This form is used for the Medicaid Estate Recovery Program in Texas. It is a worksheet that helps determine the amount of money owed to Medicaid from the estate of an individual who received Medicaid benefits.

This form is used for conducting regulatory inspections of long-term care facilities in Texas. It helps the inspection team gather and document important information about the facility's compliance with regulations and standards.

This Form is used for the Ten-Day Long-Term Care Experience Life Safety Code Facility Observation Program in Texas. It serves as a checklist to ensure compliance with safety codes in long-term care facilities.

This form is used for documenting the checklist of the ten-day long-term care experience facility observation program in Texas.

This form is used for reporting long-term care ombudsman activities in Texas. It helps gather information about the ombudsman's work in addressing issues and resolving complaints in long-term care facilities.

This document is a resource worksheet for the Texas Long-Term Care Partnership Program. It helps individuals assess their resources for long-term care and determine their eligibility for certain benefits.

This Form is used for assessing spousal impoverishment in Texas. It is available in both English and Spanish.

This form is used for communicating with managed care programs in Texas. It is used to provide information or request assistance related to healthcare services.

This form is used for confirming continued interest in the Star+Plus Home and Community Based Services Program (HCBS) in Texas. It is a program that provides home and community-based services for eligible individuals.

This form is used for conducting a Community First Choice Assessment in Texas.

This form is used for medical certification and patient transfer for Medicaid long-term care services in Florida.

This document provides instructions for completing Form FA-24A which is used for coordinating hospice services and waiver or personal care services (PCS) in Nevada.

This Form is used for applying for Long-Term Care/Waiver Medical Assistance in Maryland.

This form is used for verifying long-term care insurance policies in Texas.

This document describes the role of the Long Term Care Ombudsman in the state of Nevada. It explains their responsibilities and duties in advocating for residents in long term care facilities.

This form is used for requesting the withdrawal of HCBS (Home and Community Based Services) certification in Arizona.

This document outlines the plan for providing assisted living services in Alaska. It includes details on the services offered, facilities, and care provided to residents.

This document is used for applying for emergency licensure for hospitals and long-term care facilities in Alaska in case of emergencies or special circumstances.

This form is used for applying for Medicaid in Alaska for adults and children with long term care needs.