Get Dc Application Form

Filling out the Dc Application Form online can be a straightforward process with the right guidance. This comprehensive guide will help you navigate each section of the form, ensuring you provide all needed information accurately and efficiently.

Follow the steps to complete the application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Begin by checking the desired action for the application, such as Initial Licensure, License Renewal, or Change in Number of Beds.
3. Fill in the Facility Identification section by providing the name, telephone number, street address, city, state, and ZIP code of the facility. Indicate whether the facility is Owned or Leased and include any required documentation.
4. Complete the Type of Licensed Beds section by checking the appropriate boxes for Skilled Beds, Dual Beds, or Nursing Facility Beds. Input the total number of beds.
5. Provide the Licensee Identification details, including the name, EIN, address, and type of licensee. Check the relevant box indicating if the entity is Public, Not for Profit, or For Profit.
6. List the principals or officers of the licensee. Attach an additional sheet if needed. Repeat this for any individuals or entities with at least 10% interest in the licensee.
7. Fill in the Employee Information section, including the names and license numbers of the Administrator, Financial Officer, Director of Nursing, Medical Director, Social Service Director, and Activity Director.
8. If a management company is involved, provide its information including name, EIN, address, and ownership status.
9. Complete the Interest in Organizations section if necessary, documenting anyone with a 10-percent interest in any service provider to the facility.
10. Answer the Federal Certification questions regarding participation in Medicaid and Medicare programs and any exclusions.
11. Report any resident grievances if applicable, summarizing the number handled within the specified reporting period.
12. Attach any additional required documents, such as proof of compliance with various law requirements, insurance coverage, and financial ability.
13. Review all entries made in the form for accuracy and completeness before finalizing.
14. Once all details are accurately filled in, save your changes, and proceed to download, print, or share the completed form.

Start filling out your Dc Application Form online today to ensure a smooth application process.