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  • Shellae Dietrich, Program Specialist Linda Miller, Hfe Ni Ii Posted ...

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EY AGENCY 1. MEDICARE/MEDICAID PROVIDER NO. (L4) 1401 EAST 100TH STREET 2.STATE VENDOR OR MEDICAID NO. (L2) 180482000 01 Hospital 03/22/2012 6. DATE OF SURVEY 8. ACCREDITATION STATUS: 0 Unaccredited 2 AOA 05 HHA 09 ESRD 13 PTIP 02 SNF/NF/Dual 06 PRTF 10 NF 14 CORF 03 SNF/NF/Distinct 07 X-Ray 11 IMR 15 ASC 04 SNF 08 OPT/SP 12 RHC 16 HOSPICE 4. CHOW 5. Validation 6. Complaint 7. On-Site Visit 9. Other FISCAL YEAR ENDING DATE: (L35) 12/31 10.THE FACILITY IS CERTIFIED A.

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This guide provides a clear and comprehensive approach to filling out the Shellae Dietrich, Program Specialist Linda Miller, HFE NI II Posted ... online. Each section is outlined with step-by-step directions to ensure users can navigate the process easily, regardless of their previous experience with legal forms.

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  1. Press the 'Get Form' button to access the form in an online editor.
  2. Fill in the facility information, including the Medicare/Medicaid provider number and facility ID, ensuring accuracy in the names and addresses provided.
  3. Provide the date of the survey and select the appropriate accreditation status from the given options.
  4. Indicate whether the facility is certified as compliant with program requirements or if there are any approved waivers.
  5. Fill in the total number of beds in the facility as well as the breakdown of certified beds, adhering closely to any specified codes for different categories.
  6. Complete any remarks or additional information in the designated remarks section, ensuring clarity and detail.
  7. After reviewing all entries for accuracy, save the changes made to the form.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232