THIS REPORT IS DUE ON OR BEFORE APRIL 15, 2013-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Facility ID and Facility Name at the top of the form. This is essential for identifying your report.
3. Fill in the Mailing Address and Physical Address sections accurately, ensuring all fields are completed including city, state, and zip code.
4. In Section A, select the appropriate options for Program Type and Ownership. Be sure to indicate if there was a waiting list for services during the reporting period.
5. Complete Section B by providing patient volume data. Enter total patient days, admissions, and deaths as required in each subsection.
6. Proceed to Section C to detail admissions by reimbursement source. Ensure totals match those from previous sections.
7. Finally, review all entries for accuracy before signing off on the report in the designated signature fields at the end of the document.

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