AGING AND DISABILITY SERVICES ADMINISTRATION

Nursing Home Applications

APPLICATION PACKETS

The following types of application packets are downloadable, in full, by clicking on the corresponding link.

• Initial License  (41 pages)
• Change of Ownership (CHOW) – “Long”  (48 pages)
• Change of Ownership (CHOW) – “Short”  (48 pages)
• Change of Ownership (CHOW) – “Abbreviated”  (48 pages)
• Medicaid Contract  (39 pages)

Not sure which type of application you need?  See application types.

CIVIL RIGHTS

• U.S .Department Of Health & Human Services Office For Civil Rights
• Civil Rights Packet for Medicare Providers

RELATED MATERIALS

Download the following individual forms or informational handouts by clicking on the corresponding link:

• Background Authorization (2 pages)
• Lease or Operating Agreement Attestation  (4 pages)
• Management Agreement Attestation  (4 pages)
• Form CMS-1561 (07/01) – Health Insurance Benefit Agreement (1 page)
• Form CMS 671 (12/02) – Long-Term Care Facility Application for Medicare & Medicaid (6 pages)
• OMB 0990-0243 - Data Request Checklist ( Civil Rights Information Request for Medicare Certification) (2 pages)
• HHS-690 - Assurance of Compliance Form (1 page)
• NH Frequently Asked Questions (6 pages)
• Resource Information for Licensed Nursing Home Providers  (3 pages)
• RCS Regional Contacts (1 page)

If you are unable to view these documents online or require materials in hard copy format, please contact the Residential Care Services Business Analysis and Applications Unit at (360) 725-2420.

If you have difficulty printing these documents, please read the Print Troubleshooting Guide.