Get Facility Status Changes Form - Arizona Department Of Health Services - Azdhs
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How to fill out the Facility Status Changes Form - Arizona Department Of Health Services - Azdhs online
Filling out the Facility Status Changes Form for the Arizona Department of Health Services is an essential step for maintaining accurate facility information. This guide will walk you through each section of the form, ensuring that you complete it correctly and efficiently.
Follow the steps to complete the online form effectively.
- Press the ‘Get Form’ button to obtain the form and access it in the document editor.
- Begin by entering your CLIA number in the designated field. This number is crucial for identifying your facility.
- If your facility's changes are due to a change in ownership, check the appropriate box and ensure you complete the Disclosure of Ownership and Control Interest Statement form to accompany this submission.
- Fill in your federal tax ID number to establish your facility's tax identification for business purposes.
- Enter the new facility name, ensuring it matches your updated business registration documents.
- Provide the new facility address, including city, state, and zip code to ensure accurate location information.
- Complete the mailing address fields, which may differ from your physical location. Include the city, state, and zip code.
- Write the new director's name in the specified field, followed by their title, such as MD, DO, RN, NP, etc.
- Insert the new phone number and, if applicable, the new fax number for reaching the facility's management.
- Provide an email address for further communication regarding your facility status changes.
- Ensure the new CLIA lab director signs the form in the signature field and enters the date to validate the changes.
- After completing all fields, save your changes. You can also download, print, or share the form as needed.
Complete your Facility Status Changes Form online today to ensure your information is up-to-date and accurate.
Arizona has implemented new memory care rules to enhance the quality of care for individuals with cognitive impairments. These rules focus on staff training, facility requirements, and patient rights. If your facility is affected by these changes, you will likely need to complete the Facility Status Changes Form - Arizona Department Of Health Services - Azdhs to update your operational status. Keeping up with these regulations is essential for providing excellent care.
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