Official Federal Forms > Centers For Medicare And Medicaid Services
Long Term Care Facility Application For Medicare And Medicaid CMS 671 - Official Federal Forms
| Long Term Care Facility Application For Medicare And Medicaid Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Index No. Calendar No. : Standard Survey -againstFrom: F1 II II II To: F2 II II II MM DD YY MM DD YY Name of Facility LONG TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID : Plaintiff(s) Extended Survey JUDICIAL SUBPOENA II II DD YY Fiscal Year Ending: F5 From: F3 II : I II To: F4 II I MM DD YY MM Provider Number : City II II II MM DD YY Zip Code Street Address : County State Defendant(s) : ...................................................... Telephone Number: F6 State/County Code: F7 State/Region Code: F8 A. F9 IIPEOPLE OF THE STATE OF NEW YORK THE 01 Skilled Nursing Facility (SNF) - Medicare Participation 02 Nursing Facility (NF) - Medicaid Participation TO 03 SNF/NF - Medicare/Medicaid B. Is this facility hospital based? F10 Yes I No I If yes, indicate Hospital Provider Number: F11 IIIIIII GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Ownership: F12 I I , the Honorable at the Court For of Government located at NonProfit County Profit 01 Individual , on the 04 Church Related 07 State 10 City/County in room day of , 20 , at o'clock in the noon, and at any recessed 02 Partnership 05 Nonprofit Corporation 08 County or adjourned date, to testify and give evidence as a witness in this action on the part of the 11 Hospital District 03 Corporation 06 Other Nonprofit 09 City 12 Federal Owned or leased by Multi-Facility Organization: F13 Yes Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Name of Multi-Facility Organization: F14 result of your failure to comply. , one of the Justices of the I No I Witness, Honorable Dedicated Special Care Units (show number of beds for all that apply) Court in County, day of F15 I I I AIDS F17 I I I Dialysis F19 I I I Head Trauma F21 I I I Huntington's Disease F23 I I I Other Specialized Rehabilitation F16, 20I I Alzheimer's Disease I F18 I I I Disabled Children/Young Adults F20 I I I Hospice F22 I I I (Attorney must sign aboveCaretype name below) Ventilator/Respiratory and F24 F25 F26 F27 Yes Yes Yes Yes Does the facility currently have an organized residents group? Does the facility currently have an organized group of family members of residents? Attorney(s) for Does the facility conduct experimental research? Is the facility part of a continuing care retirement community (CCRC)? I I I I No No No No I I I I If the facility currently has a staffing waiver, indicate the type(s) of waiver(s) by writing in the date(s) of last approval. Indicate the number of hours waived for each type of waiver granted. If the facility does not have a P.O. Address in the blanks. Office and waiver, write NA Waiver of seven day RN requirement. Date: F28 II II II Hours waived per week: F29________ Waiver of 24 hr licensed nursing requirement. Date: F30 II II II Hours waived per week: F31________ MM DD YY Does the facility currently have an approved Nurse Aide Training and Competency Evaluation Program? Form CMS-671 (12/02) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: F32 Yes I No I American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : FACILITY STAFFING Tag Number Administration Physician Services Medical Director Other Physician Physician Extender Nursing Services RN Director of Nurses A Services Provided B Index No. Calendar No. Part-Time Staff (hours) C D Contract (hours) : 1 Plaintiff(s) 23 Full-Time Staff (hours) : JUDICIAL SUBPOENA -againstF33 F34 F35 F36 F37 F38 F39 F40 F41 F42 F43 F44 F45 F46 F47 : : : Defendant(s) : ...................................................... Nurses with Admin. Duties Registered Nurses Licensed Practical/ Licensed Vocational Nurses THE PEOPLE OF THE STATE OF NEW YORK TO Certified Nurse Aides Nurse Aides in Training Medication Aides/Technicians GREETINGS: Pharmacists Dietary Services WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Dietitian F48 , the Honorable at the Court F49 Food Service Workers located at County of in room Therapeutic Services , on the day of , 20 , at o'clock in the noon, and at any recessed F50 or adjourned date, to testify and give evidence as a witness in this action on the part of the F51 Occupational Therapists Occupational Therapy Assistants Occupational Therapy Aides F52 F53 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to F54 Physical Therapists the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a F55 Physical Therapists Assistants result of your failure to comply. Physical Therapy Aides F56 F57 Speech/Language Pathologist Witness, Honorable , one of the Justices of the F58 Therapeutic Recreation Specialist Qualified Activities Professional Other Activities Staff Qualified Social Workers Other Social Services Dentists Podiatrists Mental Health Services Vocational Services Clinical Laboratory Services Diagnostic X-ray Services Administration & Storage of Blood Housekeeping Services Other Name of Person Completing Form Signature Form CMS-671 (12/02) Court in County, F59 F60 F61 F62 F63 F64 F65 F66 F67 F68 F69 F70 F71 day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Time Date American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GENERAL INSTRUCTIONS AND : DEFINITIONS Index No. (use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid) This form is to be completed by :the Facility Calendar No. For the purpose of this form "the facility" equals certified beds (i.e., Medicare and/or Medicaid certified beds). : Standard Survey - LEAVE BLANK - Survey team will complete -againstExtended Survey - LEAVE BLANK - Survey team will complete INSTRUCTIONS AND DEFINITIONS Name of Facility - Use the official name of the facility for business and mail
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