Get Adh 0014 Form

Filling out the Adh 0014 Form online is a straightforward process designed to request program flexibility for adult day health care services. This guide will help you navigate each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to successfully complete the Adh 0014 Form.

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter the 'Licensee Name' in the designated field. This refers to the official name of the license holder for the center.
3. Fill in the 'Center Name' field with the name of your adult day health care facility.
4. Input your contact 'Phone Number' in the specified format, ensuring that you include the area code.
5. Complete the 'Center Address' section with the full address of your facility, including city, state, and zip code.
6. Specify the 'Requested Effective Date' for the program flexibility to take effect. Use the date format that is required.
7. Estimate how long the program flexibility will be needed in the 'Estimated Duration' field.
8. Fill out the 'Date Submitted' to indicate when you are submitting the form.
9. In the section regarding program flexibility, write the applicable Title 22, California Code of Regulations, Section(s) necessary for your request.
10. Describe the 'Reason for requesting program flexibility' clearly and concisely in the given field.
11. Provide a detailed 'Description of proposed alternative' that will help meet the intent of the regulatory requirement.
12. Explain how you have determined that the proposed alternative will not adversely affect participants by filling in that section.
13. Print the Administrator's Name in the specified field, followed by signing in the 'Administrator's Signature' box.
14. Complete the 'STATE REVIEW' section by checking 'Yes' or 'No' for CDA ADHC Branch Approval, along with the date.
15. Indicate standard flexibility approval by signing 'Yes' or 'No' and providing any comments, if needed, along with the date signed.
16. After completing the form, save your changes, and if necessary, download, print, or share the document as required.

Complete your documents online to ensure a streamlined process.