Follow the steps to complete the 9401 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in the resident information, including the first name, last name, and Medicaid number. Required fields are marked with an asterisk (*). Make sure to include a Social Security number if available.
3. Complete the facility information by providing the admission date, facility name, and contact details. Indicate if a level of care validation request is required.
4. If applicable, fill in details regarding the level of care exemption, such as hospice enrollment or Medicare Part A stay.
5. For updates, provide the date of discharge and reason for discharge. You will also need to mention any changes in income and provide the effective date.
6. Input the submitter information, including name, facility name, Medicaid provider number, email address, and telephone number.
7. Review all information filled in on the form to ensure accuracy and completeness.
8. Once all sections are completed, save any changes. You can download, print, or share the form as needed.

Complete your 9401 Form online for a seamless submission experience.