Forms and Applications
The following applications and forms are for use by nursing homes and those seeking an initial license.
Change of Ownership (CHOW)
- Nursing Home Application - Change of Ownership (PDF, 615 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 (PDF,
14 KB)
- Health Insurance Benefits Agreement,
CMS-1561 (PDF, 415 KB)
- Civil
Rights Information Request for Medicare Certification, OMB No. 0945-0006 (PDF, 81 KB)
- Medicare Enrollment Application - Institutional
Providers, CMS-855A (PDF, 1.04 MB)
Bed Breakdown
These are the forms needed for making a change to the number of certified beds in a nursing facility.
Administrator and Director of Nursing Change
Nursing homes are required to notify the Nursing Home Licensure and Certification Section within one working
day following the occurrence of change in administrator or director of nursing. Please submit the completed
Admin-DON Change form to [email protected].
- Admin-DON Change Form (DOCX, 21 KB)
Civil Money Penalty Reinvestment Program
Links to Other Government Forms
