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Click ‘Get Form’ to open it in the editor.
Begin by entering the Provider Number at the top of the form. This is essential for identifying your facility.
In Block F75, input the number of residents whose primary payer is Medicare. Repeat this for Blocks F76 and F77 for Medicaid and other payers respectively.
For total residents (Block F78), include all residents present on the survey day, even those temporarily away.
Proceed to fill out the Activities of Daily Living (ADLs) sections (F79-F93). Assess each resident's ability in bathing, dressing, transferring, toilet use, and eating based on their condition over the past week.
Continue with sections A through G, documenting bowel/bladder status, mobility, mental status, skin integrity, special care needs, medications received, and other characteristics as per definitions provided in the form.
Finally, ensure that you sign and date the form at the bottom to certify its accuracy before submission.
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RESIDENT CENSUS AND CONDITIONS OF RESIDENTS. (use with Form HCFA 672) GENERAL INSTRUCTIONS. THIS FORM IS TO BE COMPLETED BY THE FACILITY AND REPRESENTS THE CURRENT. CONDITION OF RESIDENTS AT THE TIME OF COMPLETION.
What is the CMS form 671?
The CMS 671 is the Department of Health and Human Services, Centers for Medicare and Medicaid Services form, officially known as the Long Term Care Facility Application for Medicare and Medicaid. It should be filed by nursing homes during standard surveys.
Is the CMS 672 retired?
Effective 10/22/23, the CMS-672 form is no longer in use and has been replaced with a revised CMS-671 form.
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