However, if submitted, all information is required 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the facility name and type. Select from options such as ADC, AFH, CBRF, or RCAC.
3. Fill in the address fields: street, city, county, and zip code. Ensure accuracy for proper processing.
4. Indicate the time period of your request by filling in the 'To' and 'From' dates. Specify whether it's a temporary or permanent request.
5. If applicable, provide the resident's name and indicate if they are a Family Care or IRIS member. Complete the case manager's details if necessary.
6. Clearly state the specific action requested and outline steps your facility will implement to ensure resident safety.
7. If requesting a restraint device, describe alternatives attempted and attach any relevant assessments.
8. Complete your contact information including email address and telephone number before signing the form.

Start using our platform today to streamline your document completion process for free!