Get Aclf-rha Hospice Waiver Request Form.doc. Sales And Use Tax - Health State Tn

Completing the ACLF-RHA Hospice Waiver Request Form is an essential step for assisted living facilities and residential homes to facilitate hospice services for eligible residents. This guide will provide you with clear instructions tailored to help users fill out this important document effectively.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Circle whether the request is for an ACLF or RHA in the designated section at the top of the form.
3. Fill in the 'Date' field with the current date of the request.
4. Provide the 'Facility Name' and the name of the 'Facility Staff Completing Request.'
5. Indicate the 'Current Number of Hospice Waivers Approved and Residing in Facility' along with the 'Current Census.'
6. Enter the 'Resident Name,' 'Diagnosis,' 'Physician,' and 'Admittance Date to Facility.'
7. Complete the 'Name of Hospice' and the 'Contact' information.
8. Attach the primary physician statement indicating diagnosis and prognosis. Mark 'Yes' or 'No.'
9. If the resident is unable to transfer with minimal assistance or is bedbound, confirm if 24-hour caregivers are being provided by marking 'Yes' or 'No.'
10. List the number of full-time equivalents (FTEs) in direct caregiver roles for each shift as per the form's structure.
11. Ensure a staff person is assigned to the hospice waiver approved residents on each shift for evacuation in case of an emergency.
12. Once all the information is filled out and all required documentation is attached, you can fax or mail it to the provided address.

Take action now and complete your documents online for a smoother process.