Health Facility Forms

GRAMA (Information) Request Form

Request for Administrative Review

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

Facility/Agency Info for the Licensing Application Process

1.	Information Sheet - Facility/Agency Licensing
2.	Fee Schedule
	a. Fiscal Year 2010 (July 1, 2009 - June 30, 2010) b. Fiscal Year 2011 (July 1, 2010 - June 30, 2011) c. Fiscal Year 2012 (July 1, 2011 - June 30, 2012)
3.	Notice of Intent
4.	License Application
5.	Certificate of Fire Clearance

 

 

 

 

 

 

 

 

New Provider Orientation Schedule

Policy and Procedure Information

Applicable Rules By Facility Type

Assisted Living Facility Type I - Resident Assessment

Assisted Living Facility Type II - Resident Assessment

PRN and STAT Medication Administration Record

Medication Record

Employee Health Evaluation

 

 

 

 

 

 

 

Criminal Background Screening

Individual Background Screening Application Information and Instruction

Individual Background Screening Application

Annual Renewal for Health Care Facilities

Annual Renewal (Additional Pages) for Health Care Facilities

Health Care Disclosure Statement

Request for Administrative Reveiw - Background Screening

Variance - Background Clearance - Health Facilities