Get Form 3721

Filling out Form 3721 is essential for certifying long-term care facilities for Alzheimer's disease and related disorders. This guide provides a step-by-step approach to help you navigate the form confidently and efficiently.

Follow the steps to complete and submit Form 3721.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In Part I, enter the facility name and the Alzheimer unit name if applicable. Provide the complete physical address, including street, city, state, and ZIP code, as well as the facility's area code and telephone number. Don't forget to include the county and facility identification number.
3. Indicate the current certified Alzheimer's capacity and select the type of application you are submitting: Initial, Change of Ownership, or Renewal. Different fees may apply based on your selection, as outlined in the fee schedule.
4. In Part II, ensure you have the written approval from the local fire authority for new and bed increase applications. The fire authority can sign directly on the form or provide separate written approval. Include the date of inspection as well.
5. For new applications (excluding renewals), attach a copy of the letter sent to the local health authority notifying them of the change in certification occurring at the facility.
6. In Part III, the owner or authorized representative must sign, confirming the accuracy of the information provided. Note the date of the signature and have a notary public witness your signature, including their seal.
7. Review the checklist to ensure that you have included the fee (if applicable), fire authority signature, letter to the local health authority, and notary signature/seal.
8. Once all fields are completed, save your changes, and you may choose to download, print, or share the completed form as needed.

Start completing your Form 3721 online today for efficient processing.