Get Attestation

Filling out the Attestation document is a crucial process for those seeking licensure under the deemed-by-accreditation policy. This guide provides a clear and supportive approach to completing the form efficiently and accurately.

Follow the steps to successfully complete the Attestation online.

1. Click ‘Get Form’ button to access the Attestation document and open it in an online editor.
2. Begin by entering the facility name in the designated field, which is the name under which you will conduct business.
3. Input the licensee’s name, selecting either an individual owner, partnership, limited partnership, or corporation name.
4. Provide the facility or agency address, including street address, city or town, and ZIP code.
5. Fill in the telephone and fax numbers in the indicated fields.
6. Enter the administrator's name in the corresponding section.
7. Navigate to the accreditation information section. Indicate which accrediting body recognizes your facility by checking the appropriate box.
8. Document the date of the most recent accreditation survey in the provided space and attach the results if available.
9. Specify the current accreditation period's start and end dates.
10. Confirm whether you have requested that the accrediting organization send all future reports directly to the Department of Public Health by marking 'Yes' or 'No' and providing the necessary attachments.
11. Address the Medicare certification section, indicating your Medicare status and providing the required CMS Certification Number if applicable.
12. Fill out the status as of August 10, 2008, by selecting the relevant condition from the list.
13. Review the signed and notarized statement of application section, ensuring it is complete and accurate.
14. Provide the required signatures, printed names, and dates, ensuring notarization as necessary.
15. Once completed, users can save changes, download, print, or share the Attestation form.

Complete your Attestation online today to ensure a smooth application process.