Form 9401-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I: Resident Information. Fill in the required fields marked with an asterisk, including the resident's first name, last name, and Social Security Number. If applicable, indicate whether a Medicaid application has been submitted.
3. Proceed to Section II: Facility Information - Admission. Enter the admission date and select if a Level of Care (LOC) validation request is needed. Complete the facility name and address details.
4. In Section III: Facility Information - Update, provide the date of discharge and reason for discharge by selecting from the options available.
5. For Section IV: Resident Information - Update, input any changes regarding income or personal needs account amounts as necessary.
6. Finally, complete Section V: Submitter Information by filling in your name, facility name, Medicaid provider number, email address, and telephone number before submitting.

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