3427-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the type of application you are submitting in Item 1. Check all that apply, including Initial, Recertification, or any other relevant options.
3. Fill in the identifying information for your facility in Items 2 through 10. Ensure accuracy in the name, address, and contact details.
4. In Item 20, indicate the current services your facility offers by checking all applicable boxes. For new services requested, complete Item 21 accordingly.
5. Complete staffing details in Item 30 by listing full-time equivalents for each role. Use the provided guidelines to calculate FTEs accurately.
6. Finally, review all entries for accuracy and completeness before signing off on the form in Item 34. If necessary, use the Remarks section (Item 33) for additional comments.

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