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However, if submitted, all information is required 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the facility name and type. Select from options such as ADC, AFH, CBRF, or RCAC.
- Fill in the address fields: street, city, county, and zip code. Ensure accuracy for proper processing.
- Indicate the time period of your request by filling in the 'To' and 'From' dates. Specify whether it's a temporary or permanent request.
- 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.
- Clearly state the specific action requested and outline steps your facility will implement to ensure resident safety.
- If requesting a restraint device, describe alternatives attempted and attach any relevant assessments.
- Complete your contact information including email address and telephone number before signing the form.
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