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State Licensure Forms & Publications

Forms checked are required when requesting:

Document Title

Licensure Only

Licensure and Certification with Medicare Only

Licensure and Certification with Medicare

/Medicaid

Nursing Home License Application (BHS-NHM-101)

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Facility Information Sheet (BHS-NHM-271)

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Certificate of Appointment for Authorized Representative (BHS-NHM-125)

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Surety Bond for Patient Trust Funds Held by a Nursing Home (BHS-NHM-126)

Forward the original surety fund bond for funds held in trust by the facility. The bond shall be in an amount equal to not less than 1 ¼ times the average balance of funds held during the previous year and shall be in the name of the individual facility.  A minimum $2000.00 bond is required, even if no funds are held.

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Transfer Agreement

Forward a copy of the written Transfer Agreement negotiated between owners and one or more hospitals in the area.

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Federal Certification Forms & Publications

Forms checked are required when requesting:

Document Title

Licensure Only

Licensure and Certification with Medicare Only

Licensure and Certification with Medicare

/Medicaid

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General Information Regarding Medicare/Medicaid Initial Certification and Application Documents

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Medicare Fee-For-Service Provider/Supplier Enrollment Announcements & New Information

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Application For Health Care Providers That Will Bill Medicare Fiscal Intermediaries

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Expression Of Intermediary Preference

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Information Regarding Civil Rights Clearance for Medicare Provider Certification

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Office for Civil Rights Regulations

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Medicare Certification Civil Rights Information Request Form      NOTE: FORMS ARE TO BE SENT IN TO YOUR STATE AGENCY.   DO NOT SEND THEM IN TO THE OFFICE OF CIVIL RIGHTS AS INDICATED ON THE FORM

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Assurance of Compliance Form

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Michigan RAI/MDS System Facility Application & Instructions

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Provider Enrollment Unit Medicaid Payments Division

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