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FACILITY COMMUNICATION 2026
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- Click ‘Get Form’ to open the FACILITY COMMUNICATION document in the editor.
- Begin with Section I: RESIDENT INFORMATION. Fill in the required fields marked with an asterisk (*), including First Name, Last Name, Social Security Number, and Date of Birth. If applicable, indicate whether a Medicaid application has been submitted.
- Proceed to Section II: FACILITY INFORMATION – ADMISSION. Enter the Admission Date and select the Type of Admission from the options provided. Include any relevant comments if necessary.
- Next, navigate to Section III: FACILITY INFORMATION – DISCHARGE OR DEATH. Complete the Date of Discharge and select the Reason for Discharge. Provide additional comments if needed.
- Finally, fill out Section IV: SUBMITTER INFORMATION with your name, facility name, Medicaid Provider Number, email address, telephone number, and date.
- Once all sections are completed accurately, submit the form via the secure portal within 10 business days as instructed.
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