Attachment D.3. - Application VHA -10-1170-RUG IV.pdf

Page 1 of 2VA FORM NOV 2006 (RS) 10-1170 SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information is used to determine your qualifications to provide Long-Term Care. Although this information is voluntary, failure to provide it will delay or prevent our approval of your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR APPLICATION TO

THIS ADDRESS.

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS

OMB Number 2900-0616 Estimated Burden: 10 min.

1A. NAME/ADDRESS OF PROVIDER

(Name, City, State, County & Zip)

1B. TELEPHONE NUMBER

2. MEDICARE PROVIDER NO.

3. IF THIS AGENCY IS PART OF

A CHAIN, SPECIFY WHICH ONE

4. IS PROVIDER LICENCED

OR APPROVED BY STATE

IN WHICH LOCATED

YES NO

5. PROVIDER IS CERTIFIED FOR

PARTICIPATION IN MEDICARE/

MEDICAID PROGRAM

YES NO

6. TOTAL CAPACITY

(Specify number)

7. NUMBER OF CLIENTS

ON FILING DATE

8. NAME OF PHYSICIAN WHO ADVISED AGENCY

ON PROFESSIONAL MATTERS

9A. NAME OF DIRECTOR OF NURSING SERVICE 9B. IS DIRECTOR CURRENTLY LICENCED IN

STATE WHERE NURSING HOME IS LOCATED

YES NO

9C. REGISTRATION NO.

9D. IS THERE AN IN-SERVICE TRAINING

PROGRAM FOR ALL NURSING PERSONNEL

YES NO

10A. DATE FACILITY BUILT

(N/A for home health)

10B. IS THERE AN AUTOMATIC FIRE

SPRINKLER SYSTEM THROUGHOUT THE

FACILITY

YES NO

11. INITIAL SCHEDULE OF SERVICES (Case-mix/level of care) 12. AMOUNT (Price)

(Attach additional sheets as necessary.)

Page 2 of 2VA FORM NOV 2006 (RS) 10-1170 SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

13. FINAL SCHEDULE OF SERVICES (Case-mix/level of care) 14. AMOUNT (Price)

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED

(Attach additional sheets as necessary.)

15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT

AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO

THE ISSUING OFFICE. PROVIDER AGREES TO FURNISH AND

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED

ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE

TERMS AND CONDITIONS SPECIFIED.

15B. NUMBER OF COPIES REQUIRED BY ISSUING OFFICE

16. PROVIDER AGREEMENT NUMBER

17. EFFECTIVE DATES OF AGREEMENT

(Start date/end date)

18A. SIGNATURE OF PROVIDER 19A. SIGNATURE OF VA CENTER DIRECTOR OR DESIGNEE

18B. NAME AND TITLE OF SIGNER

(Type or Print)

18C. DATE SIGNED 19B. NAME OF VA CENTER DIRECTOR OR

DESIGNEE (Type or Print)

19C. DATE SIGNED

20. COMMENTS

Page of

VA FORM

NOV 2006 (RS)

10-1170

SUPERSEDES VA FORM 10-1170, MAR 2004, WHICH WILL NOT BE USED.

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs The Paperwork Reduction Act requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and complete the form. This information is collected under the authority of Title 38, Part II, Sections 1710 and 1730. This information is used to determine your qualifications to provide Long-Term Care. Although this information is voluntary, failure to provide it will delay or prevent our approval of your agency. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden may be sent to VHA Clearance Officer (19E1); Department of Veterans Affairs; 810 Vermont Ave. NW; Washington, DC 20420. DO NOT SEND YOUR APPLICATION TO THIS ADDRESS.

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS

OMB Number 2900-0616 Estimated Burden: 10 min.

4. IS PROVIDER LICENCED OR APPROVED BY STATE IN WHICH LOCATED

5. PROVIDER IS CERTIFIED FOR PARTICIPATION IN MEDICARE/ MEDICAID PROGRAM

9B. IS DIRECTOR CURRENTLY LICENCED IN STATE WHERE NURSING HOME IS LOCATED

9D. IS THERE AN IN-SERVICE TRAINING PROGRAM FOR ALL NURSING PERSONNEL

10B. IS THERE AN AUTOMATIC FIRE SPRINKLER SYSTEM THROUGHOUT THE FACILITY

(Attach additional sheets as necessary.)

APPLICATION FOR FURNISHING LONG-TERM CARE

SERVICES TO BENEFICIARIES OF VETERANS AFFAIRS, CONTINUED

(Attach additional sheets as necessary.)

15A. THE PROVIDER IS REQUESTED TO SIGN THIS DOCUMENT AND RETURN THE NUMBER OF COPIES SPECIFIED BELOW TO THE ISSUING OFFICE. PROVIDER AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEET SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

(if it is not clear at this time, just indicate that you need more information):

RUX - Rehabilitation Plus Extensive Services (RUG IV level: ADL 16-18)

RUC - Rehabilitation (RUG IV level: ADL 16-18)

ES3 - Extensive Services (RUG IV level: ADL 2-16)

HE2 - Special Care High (RUG IV level: ADL 15-16)

LE2 - Special Care Low (RUG IV level: ADL 15-16

CE2 – Clinically Complex (RUG IV level: ADL 15-16)

BB2 – Behavior Symptoms (RUG IV level: ADL 2-5)

PE2 – Physical Function Reduced (RUG IV level: ADL 15-16) textfield: (Please enter proposed costs of care here)

$____________ or _____ % of Medicare textfield:

Total Percentage of Veteran Population Facility Can Accommodate: ___________%

Locked Unit Facility: ________Yes _________ No

Ventilator Facility: _________Yes _________ No

Small Business? _________ Yes _________No

If a Small Business, what type (Woman-owned, HUB-zone, etc.) _________________ textfield:

textfield: Contact Person/Title:

Address/City/State/Zip:

Phone/Fax No.:

E-Mail:

Tax ID No.:

DUNS No.: