Forms and Applications
The following applications and forms are for use by nursing home facilities and those seeking an initial license.
Change of Ownership (CHOW)
- Nursing Home Application - Change of Ownership (PDF, 63 KB)
- Alzheimer's Special Care Unit Required Disclosures Data Supplement (PDF, 20 KB)
- Long Term Care Facility Application for Medicare and Medicaid, CMS-671 (PDF, 367 KB)
- Breakdown of Room Numbers and Beds Within Those Rooms, DHSR-4504 (PDF, 21 KB)
- Assurance of Compliance with Title VI, HHS-690 (PDF, 7 KB)
- Health Insurance Benefits Agreement, CMS-1561 (PDF, 415 KB)
- Civil Rights Information Request for Medicare Certification, OMB No. 0990-0243 (PDF, 81 KB)
- Intermediary Designation, DHSR-4501 (PDF, 45 KB)
- Medicare Enrollment Application - Institutional Providers, CMS-855A (PDF, 1.04 MB)
- ACH Rule Choice (PDF, 59 KB)
Bed Breakdown
These are the forms needed for making a change to the number of certified beds in a nursing facility.
Links to Other Government Forms
