Get Dhmh Form 4662 November 2006 Uniform Disclosure...

Filling out the DHMH FORM 4662, the Uniform Disclosure Statement, is essential for understanding assisted living programs in Maryland. This guide provides a clear, step-by-step approach to completing the form online, ensuring that users can make informed decisions about assisted living services.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the DHMH FORM 4662 and open it in the available editor.
2. Begin by entering the Assisted Living Program Contact Information, which includes the facility name, license number, number of licensed beds, and the complete address.
3. Fill in the phone number and optional email address, as well as the names and contact information for the manager and alternate manager.
4. Specify the accepted sources of payment by indicating whether the program accepts private insurance, Medicaid, or private pay.
5. Describe the levels of care offered, including details on what characterizes each level and the associated costs.
6. Outline the resident agreement, stating its legal significance and the information it must include per regulations.
7. List the services provided, using the provided chart to indicate whether the service is offered and if it is included in the base rate.
8. Detail the discharge or transfer criteria that may necessitate moving a resident from the program, highlighting key reasons.
9. Indicate the requirements for staff training, ensuring to list the necessary training sessions per COMAR regulations.
10. Present the program’s staffing pattern, including the number of staff on each shift for different roles, and explain the staff qualifications.
11. Specify the internal complaint or grievance procedure as described in the resident agreement, ensuring that users understand how to file a complaint and seek redress.

Start completing your DHMH FORM 4662 online now to ensure a thorough understanding of the assisted living program.