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Resident specific care application printable 2026
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- Click ‘Get Form’ to open it in the editor.
- 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.
- 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.
- 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.
- 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.
- Attach necessary documents such as health assessments and service plans as outlined in the submission requirements. This ensures a complete application.
- Finally, have both the applicant and delegating nurse sign and date the form before submission to validate your request.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2012 | 4.8 Satisfied (160 Votes) |
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