Residential Care 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: 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.): Residential Care Beds: Level 3 Residential Care Beds: Level 4 Additional Info: ERC Waiver Beds VA Approved ACCS Certified Accept SSI Rates for Private Pay as of 6/2013:Private Room: Semi-Private: Services Provided: Alzheimer/Dementia Wheelchair Equipped Van Hospice Program Security Alert System Palliative Care Respite Care (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
