Get Lic 9098

The Lic 9098 form is essential for verifying corrections made to deficiencies noted during licensing visits. This guide will provide you with clear, step-by-step instructions on how to fill out the form accurately and submit it online.

Follow the steps to accurately complete the Lic 9098 form.

1. Click the 'Get Form' button to obtain the form and open it in the editor.
2. In the top section of the form, complete the facility name and facility number. This information helps identify the specific facility for which you are reporting corrections.
3. Enter the name of the licensing evaluator assigned to your facility. This contact will assist in the verification of your submitted corrections.
4. In the DEFICIENCY(IES) column, list the section number of each regulation that was violated, in the order they are presented in the corresponding Licensing Report.
5. In the PROOF OF CORRECTION column, check the appropriate box to indicate how you have verified the correction of deficiencies, such as by providing receipts, photographs, or other documentation.
6. In the DATE CORRECTED column, note the date on which each deficiency was corrected. This should only be filled in after the correction is fully made.
7. Once you have completed the form and attached supporting documentation as evidence of correction, ensure you sign the form. This signature certifies under penalty of perjury that all previously noted deficiencies have been corrected.
8. After filling out and signing the form, submit it, along with all attachments, to the licensing agency listed in the corresponding Licensing Report by the specified due date for each deficiency.

Complete the Lic 9098 form online today to ensure compliance and proper record-keeping.