Get Bhcs Ltc 110

The Bhcs Ltc 110 form is essential for notifying the Michigan Department of Licensing & Regulatory Affairs about changes in a nursing home's administrator or director of nursing. This guide will provide clear, step-by-step instructions for completing the form online, ensuring all necessary information is accurately submitted.

Follow the steps to complete the Bhcs Ltc 110 form online.

1. Click the ‘Get Form’ button to access the Bhcs Ltc 110 document and open it in your preferred editor.
2. Begin by providing the facility information in the designated fields. Enter the facility name, telephone number, address, city, zip code, facility number, and CMS CCN.
3. In the emergency contact section, list the name of the emergency contact person along with their phone number.
4. Complete the administrator information section by filling in the previous administrator's name, their ending date, and the new administrator's details, including their email address, address, city, state, zip, license number, and date appointed.
5. For the director of nursing change, enter the previous and new director's names, their email addresses, and the ending date for the previous director. Additionally, provide the new director's address, city, state, zip, license number, and date appointed.
6. Read and acknowledge the certification statement, ensuring that the provided information is accurate. Sign the document where indicated, by the authorized representative.
7. Finally, save the completed form, and you have the option to download, print, or share the document as necessary.

Complete the Bhcs Ltc 110 form online today to ensure timely compliance and reporting.