Get Rural Health Clinic Survey Report Form

Filling out the Rural Health Clinic Survey Report Form is an essential step in ensuring compliance with health care regulations. This guide provides a comprehensive, step-by-step approach to help you successfully complete the form online, ensuring that all necessary information is accurately reported.

Follow the steps to complete the form effectively.

1. Click the 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the name of the clinic along with its street number, county, city, state, and zip code in the respective fields of the form.
3. Indicate whether this is an initial survey or a resurvey by selecting the appropriate option in the provided checkbox.
4. Fill in the name and professional title of the surveyor, as well as the date surveyed.
5. Respond to the question regarding participation under Titles 18 and 19 by selecting 'Yes', 'No', or 'N/A'. Based on your response, provide explanatory statements if applicable.
6. Complete the section on compliance with Federal, State, and local laws, by marking 'Met', 'Not Met', or 'N/A' for each applicable criterion regarding clinic licensure and personnel.
7. Proceed to indicate the clinic's location, ensuring it meets the basic requirement of being in a designated shortage area.
8. Continue filling out sections regarding the physical plant, organizational structure, staffing, and provision of services, ensuring to answer all questions accurately.
9. Review the patient health records section to confirm that the clinic maintains a system in accordance with written policies.
10. Finalize by confirming that the clinic carries out its program evaluation as required, marking sections as 'Met', 'Not Met', or 'N/A'.
11. Once all sections are completed, you can save your changes, download the form, print it, or share it as needed.

Complete the Rural Health Clinic Survey Report Form online today to ensure your clinic meets necessary health standards.