Get Amendment To Application For A ... - State Of Michigan - Michigan

This guide provides comprehensive steps on how to complete the Amendment to Application for a Nursing Home form as required by the State of Michigan. By following these instructions, users can efficiently navigate the form's components and submit the necessary amendments.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to acquire the form and open it in the designated editor.
2. Fill in the facility information section. This includes the facility name, telephone number, address, city, zip code, facility number, and CMS CCN number. Ensure accuracy as this information will be used for identification and correspondence.
3. Provide the emergency contact person's name and phone number. This person should be available for urgent matters related to the facility.
4. In the administrator information section, enter the previous administrator's name and their ending date, followed by the details of the new administrator, including their email address, address, city, state, zip, license number, and date appointed.
5. Next, complete the change of director of nursing section by listing the previous director's name and ending date. Then provide the new director's details similar to the previous step, including their address, city, state, zip, license number, and date appointed.
6. Review all entries for accuracy. Certify that the information provided is true, complete, and accurate by having an authorized representative sign and date the form.
7. After completing the form, save the changes. You can then download, print, or share the form as necessary for submission.

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