FACILITY COMMUNICATION 2026

1. Click ‘Get Form’ to open the FACILITY COMMUNICATION document in the editor.
2. 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.
3. 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.
4. 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.
5. Finally, fill out Section IV: SUBMITTER INFORMATION with your name, facility name, Medicaid Provider Number, email address, telephone number, and date.
6. Once all sections are completed accurately, submit the form via the secure portal within 10 business days as instructed.

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