Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the resident's full name in the designated field at the top of the form. Make sure the name matches the documentation.
3. Input the policy number associated with the resident's account directly below the name.
4. Fill in the name of the facility where the resident is receiving care, along with the facility's telephone number and fax number.
5. Confirm that the form is being completed by the Director of Nursing or Charge Nurse, as required. Prepare to attach the itemized bill for the corresponding month.
6. Indicate the date range for the prior month’s stay using the provided fields, and if the resident was discharged, fill in the discharge date along with the discharge location.
7. If there were any overnight leaves of absence, check 'yes' and complete the sections to provide the necessary leave details. If not, select 'no'.
8. Answer whether there is a bed hold charge by selecting 'yes' or 'no'.
9. Respond to whether any of the dates listed are covered by Medicare, and if applicable, provide the details of paid-in-full and coinsurance dates.
10. Select the care level that applies: Skilled, Intermediate, Assisted Living, or Other, and provide the necessary details for any 'Other' care level.
11. Document the current diagnosis of the resident in the provided field.
12. Review the activities of daily living (ADLs) and indicate the level of assistance required for each activity by selecting the appropriate response.
13. Indicate whether the resident can self-administer medication or if assistance is required.
14. Finally, ensure that the form is signed by the appropriate person and includes their title and the date.
15. After completing the form, save your changes, and choose to download, print, or share the form as needed.

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