Long Term Care Templates

This Form is used for applying for long-term care services through the Hospital Presumptive Eligibility program in Oklahoma.

This form is used for notifying clients in Oklahoma about their long-term medical care options.

This document is for requesting a waiver of regulations for domiciliary care in Pennsylvania.

This document is used for applying to operate a Community Residential Care Facility in South Carolina.

This form is used for applying to a nursing home in South Carolina.

This document is used for scheduling Obra assessments in the state of Texas. It is specifically for Mds 3.0 assessments.

This form is used for creating a long-term care irrevocable escrow agreement specifically for solid waste landfills in Wisconsin.

This Form is used for declaring identity by individuals in institutional care facilities in Wisconsin.

This form is used for Medicaid review for the Wisconsin Veterans Home at King in Wisconsin.

This Form is used for verifying employment in the long-term care industry in Washington state.

This form is used for attesting to the annual level of need for long-term care services and supports in Washington, D.C.

This document is used for establishing a legal agreement between a beneficiary and a nursing facility in Washington, D.C. It outlines the terms and conditions of the placement and the responsibilities of both parties.

This document is used for monitoring Home and Community-Based Services (HCBS) in North Carolina. It helps ensure that proper care is being provided to individuals receiving HCBS.

This form is used for requesting action related to long-term care in Alabama.

This Form is used for requesting nursing facility rates in the state of Alabama.

This Form is used for determining the selection of Community Living Assistance and Support Services (Class) in the Waco/Temple catchment area in Texas.

This document is a Pasrr Evaluation specific to the state of Texas. It is used to assess the need for specialized services for individuals with mental illness or intellectual disabilities.

This document is used for notifying the Nebraska Home and Community-Based Waiver program of a death.

This form is used for enrolling children in the Children's Long-Term Support Waiver Program in Wisconsin. It is specifically for those who are seeking home and community-based waiver Medicaid enrollment.

This form provides age-specific answer choices for activities of daily living (ADL) and instrumental activities of daily living (IADL) for children aged 9-12 years in Wisconsin's Long-Term Support Programs.

This Form is used for creating an irrevocable trust agreement specifically for long-term care needs of solid waste landfill operators in Wisconsin.

This form is used for maintaining a roster of feeding assistants in long-term care facilities in Wisconsin.

This Form is used for obtaining a Certificate of Insurance for closure or long-term care in Wisconsin. It ensures that the necessary insurance coverage is in place for specific purposes.

This Form is used to allocate Medicaid income for community-based long-term care services in Wisconsin for individuals of Hmong background.

This document provides instructions for completing the Long Term Care Annual Report for Independent Review Organizations in West Virginia. It guides independent review organizations on what information they need to include in the report and how to submit it.

This document highlights the flexibilities provided by CMS (Centers for Medicare & Medicaid Services) to long-term care facilities, such as skilled nursing facilities and nursing facilities, in their fight against COVID-19. It includes various measures and guidelines to help these facilities manage and mitigate the impact of the pandemic.

This document is for the Long-Term Care Visitor and Staff Screening Tool used in Indiana. It helps screen visitors and staff members entering long-term care facilities for potential health risks.

This document is used to apply for a nursing home in Ohio and indicates that the applicant is ready to proceed.

This document is used to notify the Ohio Residential Care Facility of readiness for a particular event or situation. It may pertain to staff training, inspections, or other necessary preparations.

This Form is used for requesting an exemption from licensure for a home for the aged in Michigan.

This form is used for notifying a nursing home resident in North Carolina about a transfer or discharge.

This form is used for requesting ICF/IID or NF services at an RHC admission application in Washington.