49560 doc 2026

1. Click ‘Get Form’ to open the Home Health Aide Registry Application in the editor.
2. Begin by filling out the 'Aide Identification' section. Enter your full name, residential address, city, county, state, ZIP code, date of hire, telephone number, date of birth, and Social Security number. Ensure all information is accurate as it is mandatory for processing.
3. Proceed to the 'Record Competency/Skills Check' section. Input the name of the organization conducting the competency check along with its city, state, ZIP code, facility number, supervisor’s name, and the date completed.
4. In the 'Agency Identification' section, provide details such as the program director’s name, home health agency name, street address, city, facility number, agency telephone number, county, and ZIP code.
5. Finally, ensure that both you and the program director sign and date the form at the designated areas to affirm accuracy and compliance with regulations.

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