CHAPTER 514C - West Virginia Department of Health and 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date the form is completed at the top. This ensures accurate record-keeping.
3. Select the reason for submission by checking the appropriate box: Admission, Discharge, or Level of Care Change.
4. Fill in the identification information including first name, middle initial, last name, birthdate, gender, Medicaid number, and social security number.
5. Provide details about the nursing facility including its name, address, and NPI number.
6. Enter admission and discharge dates as applicable. If there is a level of care change, check either Intermediate Care or Skilled Nursing Care.
7. Complete the summary of providers section if known, detailing prior services provided to the individual before admission.
8. Finally, ensure that the person completing this form signs and dates it before submission.

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