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Click ‘Get Form’ to open the fses fillable form in the editor.
Begin by entering the Provider Number and Medicaid I.D. No. in the designated fields at the top of the form.
Fill in the facility's name and address, ensuring all required information is accurate and complete.
Indicate whether the building is fully sprinklered, partially sprinklered, or has no sprinkler system by checking the appropriate box.
Complete the survey date and plan approval date fields as necessary.
For bed composition, enter total beds and specify how many are certified for Medicaid.
Review all sections carefully before submitting to ensure compliance with fire safety standards outlined in the form.

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Versions	Form popularity	Fillable & printable
2018	4.2 Satisfied (55 Votes)
2007	4.5 Satisfied (35 Votes)

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