Uniform Disclosure Statement February 2009 DHMH Form 4662 Maryland Assisted Living Program What is the Purpose of the Disclosure Statement The purpose of the Disclosure Statement is to empower consumers by describing an assisted living program s policies and services in a uniform manner. This format gives prospective residents and their families consistent categories of information from which they can compare programs and services. 1 It is important to note that the Disclosure Statement is not intended to take the place of visiting the program talking with residents or meeting one-on-one with staff* Nor is the statement a binding contract or substitute for the Resident Agreement. Rather it serves as additional information for making an informed decision about the services provided in each program* If you have any questions about any issue raised in the Disclosure Statement or in the Resident Agreement provided by an assisted living program please seek clarification from that program s ....
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How to fill out the MD DHMH 4662 online
The MD DHMH 4662 form, also known as the Uniform Disclosure Statement, is designed to provide essential information about assisted living programs in Maryland. This guide will walk you through the steps needed to fill out this form accurately and efficiently online, ensuring you have the information needed for an informed decision.
Follow the steps to complete the MD DHMH 4662 online.
- Press the ‘Get Form’ button to access the MD DHMH 4662 document online and open it in your preferred editor.
- Enter the assisted living program contact information, including the facility name, license number, number of licensed beds, address, phone number, and email address. Make sure all fields are filled out completely.
- Indicate the accepted sources of payment for the program, such as private insurance, Medicaid, or private pay.
- Detail the levels of care provided by the facility based on the needs of residents. Specify if the facility offers more than the standard three levels of care recognized by the State.
- Describe the Resident Agreement and its significance as a legal contract that outlines the obligations of both the resident and the facility.
- List the services provided by the facility, ensuring to distinguish between those included in the base rate and services that may require additional charges.
- Outline the criteria for discharge or transfer of residents, making sure to cover all pertinent policies and procedures.
- Provide information on staff training requirements, as mandated by COMAR, which includes specifics on the training of managers and staff.
- Detail the staffing pattern required by the facility to meet the 24-hour needs of residents.
- Include information regarding the complaint process available to residents, including internal grievance procedures and external reporting mechanisms.
- Review and save your completed form. You may download, print, or share the form as needed.
Complete the MD DHMH 4662 form online to ensure you have crucial information about assisted living programs.
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