LARA - Licensing and Certification Forms for Nursing Homes

Licensing and Certification Forms for Nursing Homes

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State Licensure Forms & Publications	Forms checked are required when requesting:
Document Title	Licensure Only	Licensure and Certification with Medicare Only	Licensure and Certification with Medicare/Medicaid
Nursing Home License Application (BHCS-LTC-101)	√	√	√
Facility Information Sheet (BHCS-LTC-271)	√	√	√
Certificate of Appointment for Authorized Representative (BHCS-LTC-125)	√	√	√
Surety Bond for Patient Trust Funds Held by a Nursing Home (BHCS-LTC-126) Forward the original surety fund bond for funds held in trust by the facility. The bond shall be in an amount equal to not less than 1¼ times the average balance of funds held during the previous year and shall be in the name of the individual facility. A minimum $2000.00 bond is required, even if no funds are held.	√	√	√
Transfer Agreement Forward a copy of the written Transfer Agreement negotiated between owners and one or more hospitals in the area.	√	√	√

To request Certification, in addition to the above forms, you must request enrollment in MEDICARE AND MEDICAID using the Center for Medicare and Medicaid Services enrollment process. Please note that the Division of Nursing Home Monitoring is not involved in this process.

Federal Certification Forms & Publications	Forms checked are required when requesting:
Document Title	Licensure Only	Licensure and Certification with Medicare Only	Licensure and Certification with Medicare/Medicaid
Survey and Certification Guidance for Laws and Regulations		√	√
General Information Regarding Medicare/Medicaid Initial Certification and Application Documents		√	√
Medicare Fee-For-Service Provider/Supplier Enrollment Announcements & New Information		√	√
Application For Health Care Providers That Will Bill Medicare Fiscal Intermediaries		√	√
Expression Of Intermediary Preference		√	√
Information Regarding Civil Rights Clearance for Medicare Provider Certification		√	√
Office for Civil Rights Regulations		√	√
Medicare Certification Civil Rights Information Request Form NOTE: FORMS ARE TO BE SENT IN TO YOUR STATE AGENCY. DO NOT SEND THEM IN TO THE OFFICE OF CIVIL RIGHTS AS INDICATED ON THE FORM.		√	√
Assurance of Compliance Form		√	√
RAI/MDS Transmissions System Facility Information Form		√	√
Provider Enrollment Unit Medicaid Payments Division			√

Nursing homes must meet the licensure rules and federal regulations for certification. In addition the home must meet requirements of Parts 201 and 217 of the Michigan Public Health Code. You will want to look at all of the links available to you here:

Nursing Home Rules and Regulations

Medicaid Provider Manual

Licensing and Certification Forms for Nursing Homes

Transfer Agreement

Office for Civil Rights Regulations