R for a Long-Term Care Facility http://hfs.health.ok.gov This Disclosure Statement is being submitted for the following type of review: Initial License Amendment to previous filing Renewal License 1. Facility Identification Suspended License Facility ID # Facility Name (d.b.a. name): 2. Owner(s)/Lessor(s) of Building, Land and Equipment Information A. Name of Owner(s)/Lessor(s): Street City State Telephone Number: Zip Fax Number: B. If this Entity is a Government Entity check the typ.
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How to fill out the HRDS HFS 953 B Disclosure Statement online
Filling out the HRDS HFS 953 B Disclosure Statement online is a straightforward process that requires careful attention to detail. This guide aims to provide clear and structured steps to assist you in completing the form accurately and efficiently.
Follow the steps to complete the HRDS HFS 953 B Disclosure Statement.
- Click 'Get Form' button to obtain the form and open it in your digital editor.
- Begin by providing basic facility identification details in Section 1. This includes the facility ID number, name, and the type of review being submitted, such as Initial License or Renewal License.
- In Section 2, list the owner(s) or lessor(s) of the building, land, and equipment. Include their name, address details, and contact numbers. If applicable, check the box for the type of government entity.
- Proceed to Section 3 to fill in the lessee information. If the facility is leased, confirm by selecting 'Yes' and complete the lessee details. Attach any necessary forms as indicated.
- In Section 4, indicate whether there is a contracted manager or supervisor. If 'Yes', provide their information and check the government entity type, if applicable.
- Complete Section 5 by submitting a copy of the Affirmation Attachment (ODH Form 953-D) for individuals who hold an interest in the facility.
- Finally, in Section 6, note any changes that have occurred regarding ownership, leasing, or management and provide effective dates for these changes.
- Once all sections are completed, review your entries for accuracy. You can then save your changes, download, print, or share the completed form as needed.
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