Long term care application form: Fill out & sign online

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Click ‘Get Form’ to open the CMS 671 in the editor.
Begin by entering the official name of the facility in the 'Name of Facility' field. Ensure this is accurate for business and mailing purposes.
In the 'Provider Number' section, leave it blank for initial certifications. For recertifications, input your facility’s six-digit provider code.
Fill in the 'Street Address', ensuring it reflects the physical location. Include city and county details accurately.
Indicate whether your facility is hospital-based by checking 'Yes' or 'No' in Block F10, and provide any necessary hospital provider number if applicable.
For ownership type, select from options provided in Block F12, indicating whether it's for-profit, non-profit, or government-operated.
Complete sections regarding dedicated special care units (Blocks F15-F23) by entering the number of beds allocated for each specific need.
Finally, ensure to sign and date at the bottom of the form after filling out all required fields.

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