Get I6yt11 - Minnesota Department Of Health

The I6YT11 form is essential for organizations seeking Medicare and Medicaid certification through the Minnesota Department of Health. This guide provides a structured approach to complete the form online, ensuring all necessary information is accurately captured.

Follow the steps to complete your I6YT11 form effectively.

1. Click the ‘Get Form’ button to download the I6YT11 form and open it in your desired editor.
2. Begin with Part I. Fill in the 'Medicare/Medicaid Provider Number' field located at line 1. Make sure this number is correct as it identifies your facility.
3. In line 2, enter your 'State Vendor or Medicaid Number'. This is important for proper identification and processing.
4. Next, provide the 'Name and Address of Facility' in lines 3 and 4. Ensure this information matches your official documentation to avoid any processing delays.
5. In line 5, you will indicate the 'Effective Date of Change of Ownership', if applicable. This field should reflect the correct date to ensure accurate processing.
6. Complete line 6 with the 'Date of Survey'. This is the date your facility was last inspected or surveyed.
7. Proceed to line 8. Here, you will indicate your 'Accreditation Status'. Select the appropriate option from the list provided.
8. For lines 12 and 13, report the 'Total Facility Beds' and 'Total Certified Beds'. Ensure these numbers reflect your current capacity.
9. In line 10, check the appropriate box to certify that your facility is compliant with relevant standards.
10. Finalize the form by reviewing all entries for accuracy. Once satisfied, save your changes, download a copy for your records, and prepare to submit as required.

Complete your I6YT11 form online now to ensure your facility's compliance and certification.