Resident specific care application printable 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Assisted Living Manager's name and phone number at the top of the form. This information is crucial for communication regarding the waiver request.
3. Fill in the name and address of the Assisted Living Program, along with census details, licensed capacity, and level of care. Ensure accuracy as this data reflects your facility's capabilities.
4. Indicate the number of resident-specific waivers currently in effect. Check applicable boxes to confirm authorization for providing a level of care beyond current licensure.
5. In the section requesting a waiver, clearly state the resident’s name and provide justification for the request. Specify if their required level of care exceeds what your facility can currently offer.
6. Attach necessary documents such as health assessments and service plans as outlined in the submission requirements. This ensures a complete application.
7. Finally, have both the applicant and delegating nurse sign and date the form before submission to validate your request.

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