Common Contracts
1 similar Medicaid Agreement contracts
ContractMedicaid Agreement • February 25th, 2021
Participating facility Name: Federal Medicare Provider #: Corporation/Organization Name (If applicable): Address: Phone: Administrators Name: Administrators Email Address: Survey Champion Name (if different than administrator): Survey Champion Email Address: Licensed Skilled Nursing Bed Count: Total number of Long-Stay Residents with a of BIMS 8+: OPTIONAL EMPLOYEE SURVEY: (check yes or no) ☐ Yes / ☐ No Total Number of Employees if surveying (Full / Part time):
