Facility Information The ADC is located in or attached to: One- or two-family dwelling Stand-alone facility Multi-use building not attached to a healthcare facility (such as a church, community room, or senior center) Assisted living or other healthcare facility a nursing home (such as a CBRF, RCAC, or general hospital) not Nursing home or area of a hospital designated “swing beds” Certificate Holder Type (Check one. Do not facility will be owned and operated by a state agency.) check “Government – State” unless Church Government County Limited Liability Corporation (LLC) – Corporation For-Profit Government State Partnership – Corporation Non-Profit Government Other Proprietorship (individual) – Tribal Other Specify: – Owner / Operator / Certificate Holder Information Name Corporation / Legal Entity (if applicable) FEIN (Federal Employer Identification No.) – Name Certificate Holder or Corporate Entity Birthdate Certificate Holder or Corporate Rep. – – Address Certificate Holder / Corporate Representative City State Zip Code – Telephone No. Fax No. Email Address Provide the name(s) of any other facilities associated with this certificate holder or corporate entity. Attach an additional list if needed. Participant Information Total Number of ADC Participants Served: Yes No Will meals be provided to participants? Yes No Are any participants non-ambulatory? Check only the box(es) indicating the primary participant group(s) you will serve. Irreversible Dementia / Advanced Age Alzheimer’s Emotionally Disturbed / Mental Illness Developmentally Disabled (Intellectually Impaired) Terminally Ill Physically Disabled Traumatic Brain Injury Other (Specify.) Currently serving publicly funded participants (Identify the agency providing the public funding below.) Anticipate serving publicly funded participants within the next 90 days To be eligible to receive public funding, facilities must demonstrate compliance with The Centers for Medicare & Medicaid Services (CMS) Home and Community-Based Services (HCBS) settings rule during the onsite survey. Review the additional requirements listed on page 4 of this application. Safety Local fire departments have requested the locations of regulated facilities. Provide the details of your local fire department. Name Local Fire Department Telephone No. (do not – enter “911”) Street Address / PO Box City State Zip Code
Facility Information The ADC is located in or attached to: One- or two-family dwelling Stand-alone facility Multi-use building not attached to a healthcare facility (such as a church, community room, or senior center) Assisted living or other healthcare facility not a nursing home (such as a CBRF, RCAC, or general hospital) Nursing home or area of a hospital designated “swing beds” Certificate Holder Type (Check one. Do not check “Government – State” unless facility will be owned and operated by a state agency.) Church Corporation For-Profit Corporation Non-Profit Government – County Government – State Government – Other Tribal Limited Liability Corporation (LLC) Partnership Proprietorship (individual) Other – Specify: Owner / Operator / Certificate Holder Information Name – Corporation / Legal Entity (if applicable) FEIN (Federal Employer Identification No.) Name – Certificate Holder or Corporate Entity Birthdate – Certificate Holder or Corporate Rep. Address – Certificate Holder / Corporate Representative City State Zip Code Telephone No. Fax No. Email Address Provide the name(s) of any other facilities associated with this certificate holder or corporate entity. Attach an additional list if needed. Participant Information Total Number of ADC Participants Served: Yes No Will meals be provided to participants? Yes No Are any participants non-ambulatory? Check only the box(es) indicating the primary participant group(s) you will serve. Advanced Age Developmentally Disabled (Intellectually Impaired) Physically Disabled Traumatic Brain Injury Irreversible Dementia / Alzheimer’s Emotionally Disturbed / Mental Illness Terminally Ill Other (Specify.) Currently serving publicly funded participants (Identify the agency providing the public funding below.) Anticipate serving publicly funded participants within the next 90 days To be eligible to receive public funding, facilities must demonstrate compliance with The Centers for Medicare & Medicaid Services (CMS) Home and Community-Based Services (HCBS) settings rule during the onsite survey. Review the additional requirements listed on page 4 of this application. Safety Local fire departments have requested the locations of regulated facilities. Provide the details of your local fire department. Name – Local Fire Department Telephone No. (do not enter “911”) Street Address / PO Box City State Zip Code
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