4449c form 2026

1. Click ‘Get Form’ to open the 4449c form in the editor.
2. Begin by filling in the Resident/Patient Name and Date of Birth at the top of the form. Ensure accuracy as this information is crucial for identification.
3. In the Facility Name section, provide the name and address of the facility where the individual resides. This helps in verifying their current living situation.
4. Check all applicable boxes under 'Check all that apply' to indicate the type of evaluation being conducted, such as Initial or RUG Category Change.
5. Complete the medical history section by detailing significant medical conditions, allergies, and current medications. Use additional sheets if necessary.
6. Indicate whether assistance is needed for self-administration of medications and check appropriate options for continence and supervision needs.
7. Finally, ensure that a physician or authorized personnel signs and dates the form to validate its contents before submission.

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