Nursing Home Membership Application Back to main page Facility Name:* Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:* Email:* Fax: Federal Medicare Provider Number: VHCA Designated Voting Rep.: Owner/Affiliation: Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website: Tax Status:For-ProfitNon-ProfitHospital BasedYear Established: # Currently on Staff (all dept.): Nursing Facility Beds: Level 1 Nursing Facility Beds: Level 2 Residential Care Beds: Level 3 Residential Care Beds: Level 4 Additional Info: Medicare Certified Medicaid Certified ERC Waiver Beds JCAHO Accredited VA Approved Rates for Private Pay as of 6/2013:Private Room: Semi-Private: Services Provided: Alzheimer/Dementia Managed Health Care Out Patient Therapy Sub Acute Care/Rehab Wheelchair Equipped Van Security Alert System Hospice Program Occupational Therapy Respiratory Therapy Restorative Therapy Speech Therapy On Site Adult Day Care IV Therapy Palliative Care Wound Care Respite Care Physical Therapy (please check all that apply)Department HeadsAdministrator Name: Email: Director of Nursing Name: Email: Activity Director Name: Email: Dietary Director Name: Email: Social Services Director Name: Email: Maintenance Director Name: Email: Medical Director Name: Email: Comments or Questions: Δ
