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Forms
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Ambulatory Care Assessment
| Number |
Title of Document |
PDF |
MS Word |
Instructions |
| HFEL-5 |
Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment |
pdf 12k |
doc 33k |
Instructions
to complete the form
pdf 10k
doc 22k |
Certificate of Need and Acute Care Licensure
| Number |
Title of Document |
PDF |
MS Word |
| CN-1 |
Application-Full Review Certificate of Need
Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds
|
82K |
447K |
| CN-3 |
Application for Certificate of Need for Hospital-Related Projects - Full Review |
121K |
521K |
| CN-4 |
Application for Certificate of Need for Designation as a Perinatal Facility |
128K |
224K |
| CN-7 |
Application for New or Amended Acute Care Facility License
Fees for Licensure and Inspection [pdf 13k] |
128K |
287K |
| CN-10 |
Annual Report of Megavoltage Radiation Unit |
17k |
60k |
| CN-12 |
Report of Influenza and Pneumococcal
Immunization As Required in Hospital Regulation and Rehabilitation
Hospital Regulation (On-line Form) |
58K |
31K |
| CN-19 |
Certificate of Need Application - Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a) |
61K |
107K |
| CN-28, 28a |
Application for Waiver Request |
54K |
34K |
| CN-29 |
Fee Schedule for Printed Materials
|
72K |
40K |
|
Long Term Care Forms and Publications
General
| Form
# |
Title |
PDF |
Word |
Instructions |
| AAS-11 |
Nurse Staffing Report |
13k |
54k |
|
| AAS-45 |
Reportable
Event Record/Report |
43K |
52K |
|
| AAS-55 |
Declaration of Compliance with Advisory Standards |
74K |
137K |
|
| HFEL-3 |
Project Application for an Adult Day Health Services Facility |
18K |
43K |
|
| HFEL-4 |
Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility |
16K |
39K |
|
| LCS-4 |
Communicable Disease Alert |
28K |
28K |
|
| LCS-5 |
Application for the Addition of Long Term Care Beds |
86K |
37K |
|
| LCS-8 |
Facility Reporting Incident Data and Analysis Yield (FRIDAY) Form |
44K |
119K |
|
| LCS-9 |
Application for Health Care Facility License |
42K |
145K |
|
| LTC-2 |
Notification
from Long-Term Care Facility of Admission or Termination of
a Medicaid Patient |
36K |
60K |
Instructions
to complete the form (PDF)
(WORD) |
| LTC-4 |
Hospital
Preadmission Screening Referral |
46K |
32K |
|
| LTC-8 |
Hospital
Pre-admission Screening Discharge |
32K |
28K |
|
| LTC-19 |
Request
for Billing Assistance |
46K |
30K |
|
Nursing Home Administrator Licensure and Licensing
Board
| Form
# |
Title |
PDF |
Word |
Additional
Information |
| NH-1 |
Application
for Nursing Home Administrator License |
68K |
66K |
Letter
to Applicant
PDF 7086K |
| NH-3 |
Application
for Renewal of Nursing Home Administrator License for the
Period July 1, 2001 through June 30, 2003 |
79K |
84K |
Letter
to Applicant
PDF 321K |
| NH-5 |
Application
for Approval of Continuing Education Program for Licensed
Nursing Home Administration |
88K |
38K |
Letter
to Applicant
PDF 69K |
| NH-6 |
Verification
of Out-of-State Licensure Status |
63K |
33K |
|
| NH-8 |
Application
for Approval of Nursing Home Administrator-in-Training Program
or Assistant Administrator Position |
65K |
34K |
|
| NH-9 |
Quarterly
Progress Report for Nursing Home Administrator-in-Training
Program or Assistant Administrator Position |
65K |
34K |
|
| NH-10 |
Certification
for Program Completion for Nursing Home Administrator-in-Training
Program or Assistant Administrator Position |
76K |
40K |
|
Applications/Forms/Instructions
Revised Fee Schedule for CN Applications as of July 1, 2003 (pdf 7k)
Long Term Acute Care Services Bed Need (pdf 65k)
Fees for the Licensure and Biennial Inspection of Acute Care Facilities (pdf 13k) (4/19/2004)
To review Provider Enrollment Procedures, click the appropriate Provider type:
Translated Banking and Insurance, HIPAA and NJ Health Care Forms
The sample health care forms on this page have been translated into four languages: Haitian Creole, Mandarin Chinese, Hindi and Spanish. The forms are offered free of charge to facilitate communication between patients and health care workers, and to reduce disparities. |
Division of Health Facilities Evaluation and Licensing
