Health Facility Forms

GRAMA (Information) Request Form

Request for Administrative Review


Electronic Health Care Facility Complaint Submission

Electronic Complaint Form
Electronic Entity Report Form

Life with Dignity (Physician Orders for Life-Sustaining Treatment):

Life with Dignity (POLST) - (english)

Life with Dignity (POLST) - (spanish)

Provider Guide - Life with Dignity (POLST)


Other Helpful Provider Forms

Orientation Training Record
Competency Training Record
Inservice Training Record
Assisted Living Service Plan
Assisted Living Hospice Evacuation Example Form
Patient Safety Sentinel Event Reporting Form
Negotiated Risk Contract
Variance Request Application
Incident Report
Personal Care Aide Evaluation
Nurse Delegation Letter

Health Facility Commitee

Birthing Center Meeting Audio Recording - November 6, 2008
Birthing Center Meeting Audio Minutes - December, 2008

Facility/Agency Info for the Licensing Application Process


Fee Schedule
License Application
6. Satellite Notice of Intent
7. Mammography Application
















Criminal Background Screening