Get Al Anha Region Iv / Atlanta Emergency Response Cmp Application

This guide will provide you with a detailed walkthrough of how to complete the AL ANHA Region IV / Atlanta Emergency Response CMP Application online. It aims to clarify each section of the application to ensure that all required information is accurately submitted.

Follow the steps to effectively complete your application.

1. Click the ‘Get Form’ button to obtain the application form and open it for editing.
2. Fill in the date of the application at the beginning of the form. Ensure to use the MM/DD/YYYY format.
3. Complete the nursing home background information. This includes the facility name, address, CMS certification number, and contact details.
4. Document your nursing home's survey history. Include dates and highest scope and severity of surveys.
5. Indicate whether the facility is enrolled in the Special Focus Facility initiative and provide relevant information if in bankruptcy.
6. Next, address alternative emergency funding sources. Indicate if any current loans or funding requests have been made.
7. Describe the emergent event in detail. Include start and end dates, number of residents affected, and whether an emergency declaration was in effect.
8. Select the type of emergency that impacted your facility from the provided options.
9. List the actions taken by the nursing home in response to the emergency, including evacuation details if applicable.
10. Select the amount of funding you are requesting and specify if the application is to cover insurance deductibles.
11. Detail the specific needs for which CMP funds are being requested, both for operational and workforce-related expenditures.
12. Complete the attestation statement by signing and dating the document, ensuring that all representatives have also provided their signatures.
13. Assemble the application and supplementary documentation as a single PDF file, ensuring adherence to the specified formatting guidelines.
14. Submit the complete application electronically to the appropriate Region IV State Survey Agency.
15. After submission, wait for confirmation from the State Survey Agency regarding the receipt and processing of your application.

Start filling out your AL ANHA Region IV / Atlanta Emergency Response CMP Application online today.