| OQA-0287
|
Community Based Residential Facility Initial Application
|
PDF - Print
|
None
|
English
|
| OQA-0287
|
Community Based Residential Facility Initial Application
|
Word - Fillable
|
None
|
English
|
| OQA-0290
|
CBRF Identification of Hazards Request
|
PDF - Print
|
None
|
English
|
| OQA-0290
|
CBRF Identification of Hazards Request
|
Word - Fillable
|
None
|
English
|
| OQA-0309
|
Self Supervision Evaluation and Waiver Request*
|
PDF - Print
|
None
|
English
|
| OQA-0309
|
Self Supervision Evaluation and Waiver Request*
|
Word - Fillable
|
None
|
English
|
| OQA-0367
|
Community Advisory Committee Documentation
|
PDF - Print
|
None
|
English
|
| OQA-0367
|
Community Advisory Committee Documentation
|
Word - Fillable
|
None
|
English
|
| OQA-0783
|
Community Based Residential Facility (CBRF) Independent Apartment Inspection Checklist and Certification
|
PDF - Print
|
Program Staff
|
English
|
| OQA-0795
|
Fire Inspection Community Based Residential Facility (CBRF)
|
PDF - Print
|
None
|
English
|
| OQA-0795
|
Fire Inspection Community Based Residential Facility (CBRF)
|
Word - Fillable
|
None
|
English
|
| OQA-0820
|
Corporate Guardianship Status Application*
|
PDF - Print
|
None
|
English
|
| OQA-0820
|
Corporate Guardianship Status Application*
|
Word - Fillable
|
None
|
English
|
| OQA-0923
|
Statement of Financial Condition of a Prospective Resident of a Community Based Residential Facility (CBRF)
|
PDF - Print
|
None
|
English
|
| OQA-0923
|
Statement of Financial Condition of a Prospective Resident of a Community Based Residential Facility (CBRF)
|
Word - Fillable
|
None
|
English
|
| OQA-0945
|
Adult Family Home License Application / Report
|
PDF - Print
|
None
|
English
|
| OQA-0945
|
Adult Family Home License Application / Report
|
Word - Fillable
|
None
|
English
|
| OQA-0947
|
Adult Day Care Certification Standards Checklist
|
PDF - Print
|
None
|
English
|
| OQA-0947
|
Adult Day Care Certification Standards Checklist
|
Word - Fillable
|
None
|
English
|
| OQA-0953
|
Adult Family Home Fire Safety Guide
|
PDF - Print
|
None
|
English
|
| OQA-0953
|
Adult Family Home Fire Safety Guide
|
Word - Fillable
|
None
|
English
|
| OQA-2019
|
License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease
|
PDF - Print
|
None
|
English
|
| OQA-2019
|
License Application - Nursing Home, Facility for the Developmentally Disabled or Institute for Mental Disease
|
Word - Fillable
|
None
|
English
|
| OQA-2022
|
Facility Nursing License Verification List
|
Paper
|
OQA
|
English
|
| OQA-2022A
|
Instructions For Facility Documentation Forms
|
Paper
|
OQA
|
English
|
| OQA-2023
|
Facility Report Of Registered Nurse Time Schedule - Days
|
Paper
|
OQA
|
English
|
| OQA-2024
|
Nurse Aide Hours Worked - Days
|
Paper
|
OQA
|
English
|
| OQA-2025
|
Facility Report Of Registered Nurse Time Schedule - Evening
|
Paper
|
OQA
|
English
|
| OQA-2026
|
Facility Report Of Aide Or Orderly Time Schedule - Evening
|
Paper
|
OQA
|
English
|
| OQA-2027
|
Facility Report Of Registered Nurse Time Schedule - Nights
|
Paper
|
OQA
|
English
|
| OQA-2028
|
Facility Report Of Aide Or Orderly Time Schedule - Nights
|
Paper
|
OQA
|
English
|
| OQA-2030
|
Facility Resident Census
|
Paper
|
OQA
|
English
|
| OQA-2062
|
Hospice License Application
|
PDF - Print
|
None
|
English
|
| OQA-2062
|
Hospice License Application
|
Word - Fillable
|
None
|
English
|
| OQA-2069
|
Home Health Agency Complaint Report*
|
PDF - Print
|
None
|
English
|
| OQA-2069
|
Home Health Agency Complaint Report*
|
Word - Fillable
|
None
|
English
|
| OQA-2082
|
Title XIX Care Level Determination Request For Information
|
Word - Fillable
|
None
|
English
|
| OQA-2092
|
Hospital Certificate of Approval Application*
|
PDF - Print
|
None
|
English
|
| OQA-2092
|
Hospital Certificate of Approval Application
|
Word - Fillable
|
None
|
English
|
| OQA-2151
|
Nursing Home Residents' Rights Complaint Report*
|
PDF - Print
|
None
|
English
|
| OQA-2151
|
Nursing Home Residents' Rights Complaint Report*
|
Word - Fillable
|
None
|
English
|
| OQA-2155
|
Living Unit Census Report
|
Paper
|
OQA
|
English
|
| OQA-2155A
|
Instructions For Completion Of Facility Documentation Forms
|
Paper
|
OQA
|
English
|
| OQA-2156
|
Living Unit Direct Care Staff Report - Day Shift
|
Paper
|
OQA
|
English
|
| OQA-2157
|
Living Unit Direct Care Staff Report - Evening Shift
|
Paper
|
OQA
|
English
|
| OQA-2158
|
Living Unit Direct Care Staff Report - Night Shift
|
Paper
|
OQA
|
English
|
| OQA-2164
|
Facility Report / LPN Time Schedule-day
|
Paper
|
OQA
|
English
|
| OQA-2165
|
Facility Report / LPN Time Schedule-evening
|
Paper
|
OQA
|
English
|
| OQA-2166
|
Facility Report LPN Time Schedule-night
|
Paper
|
OQA
|
English
|
| OQA-2194
|
Title XIX Recipient Termination Notice*
|
PDF - Print
|
None
|
English
|
| OQA-2194
|
Title XIX Recipient Termination Notice*
|
Word - Fillable
|
None
|
English
|
| OQA-2220
|
Nurse Aide Instructional Program Application
|
PDF - Print
|
None
|
English
|
| OQA-2220
|
Nurse Aide Instructional Program Application
|
Word - Fillable
|
None
|
English
|
| OQA-2224
|
Notice of Substantial Change Nurse Aide Training Program
|
PDF - Print
|
None
|
English
|
| OQA-2224
|
Notice of Substantial Change Nurse Aide Training Program
|
Word - Fillable
|
None
|
English
|
| OQA-2249
|
Annual Report - Nurse Assistant/home Health Aide Training / Testing Program
|
Paper
|
OQA
|
English
|
| OQA-2256
|
Request for Title XIX Care Level Determination*
|
PDF - Print
|
None
|
English
|
| OQA-2256
|
Request for Title XIX Care Level Determination
|
Word - Fillable
|
None
|
English
|
| OQA-2256A
|
Request for Title XIX Care Level Determination Addendum for Developmentally Disabled Client / Residents*
|
PDF - Print
|
None
|
English
|
| OQA-2256A
|
Request for Title XIX Care Level Determination
|
Word - Fillable
|
None
|
English
|
| OQA-2281
|
Care Level Change Notice
|
PDF - Print
|
None
|
English
|
| OQA-2281
|
Care Level Change Notice
|
Word - Fillable
|
None
|
English
|
| OQA-2287
|
Hospice Patient Complaint*
|
PDF - Print
|
None
|
English
|
| OQA-2287
|
Hospice Patient Complaint*
|
Word - Fillable
|
None
|
English
|
| OQA-2288
|
Care Level Determination Worksheet
|
PDF - Print
|
None
|
English
|
| OQA-2308
|
Authorization to Accept Personal Service and Receive Registered and Certified Mail*
|
PDF - Print
|
None
|
English
|
| OQA-2308
|
Authorization to Accept Personal Service and Receive Registered and Certified Mail*
|
Word - Fillable
|
None
|
English
|
| OQA-2333
|
Plan Approval Application and Instructions*
|
PDF - Print
|
None
|
English
|
| OQA-2333
|
Plan Approval Application and Instructions
|
Word - Fillable
|
None
|
English
|
| OQA-2365A
|
Mailing Label - Plan Review
|
Paper
|
OQA
|
English
|
| OQA-2365B
|
Mailing Label - BNHRC
|
Paper
|
OQA
|
English
|
| OQA-2369
|
Waiver of Hospice or Home Health Services by a Terminally Ill CBRF Resident*
|
PDF - Print
|
Form Center
|
English
|
| OQA-2369
|
Waiver of Hospice or Home Health Services by a Terminally Ill CBRF Resident*
|
Word - Fillable
|
None
|
English
|
| OQA-2370
|
Significant Change in Health Screening Instrument
|
PDF - Print
|
Form Center
|
English
|
| OQA-2370
|
Significant Change in Health Screening Instrument
|
Word - Fillable
|
None
|
English
|
| OQA-2371
|
Individual Service Plan - ISP
|
PDF - Print
|
None
|
English
|
| OQA-2371
|
Individual Service Plan - ISP
|
Word - Fillable
|
None
|
English
|
| OQA-2372
|
Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
|
PDF - Print
|
None
|
English
|
| OQA-2372
|
Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation
|
Word - Fillable
|
None
|
English
|
| OQA-2373
|
Resident Evacuation Assessment
|
PDF - Print
|
None
|
English
|
| OQA-2373
|
Resident Evacuation Assessment
|
Word - Fillable
|
None
|
English
|
| OQA-2380
|
Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application
|
PDF - Print
|
None
|
English
|
| OQA-2380
|
Residential Care Apartment Complex (RCAC) Initial Certification or Registration Application
|
Word - Fillable
|
None
|
English
|
| OQA-2381
|
Residential Care Apartment Complex Regulations Compliance Statement
|
PDF - Print
|
None
|
English
|
| OQA-2381
|
Residential Care Apartment Complex Regulations Compliance Statement
|
Word - Fillable
|
None
|
English
|
| OQA-2415I
|
CBRF Training Program Approval Request & Instructions
|
Paper
|
Form Center
|
English
|
| OQA-2416
|
Community Based Residential Facility (CBRF) Initial Licensure Checklist
|
PDF - Print
|
None
|
English
|
| OQA-2416
|
Community Based Residential Facility (CBRF) Initial Licensure Checklist
|
Word - Fillable
|
None
|
English
|
| OQA-2418
|
Adult Day Care Initial Certification Application
|
PDF - Print
|
None
|
English
|
| OQA-2418
|
Adult Day Care Initial Certification Application
|
Word - Fillable
|
None
|
English
|
| OQA-2428
|
Annual Inpatient Health Care Facility Fee Notice
|
PDF - Print
|
None
|
English
|
| OQA-2430
|
Community Based Residential Facility Residents' Rights Complaint Report*
|
PDF - Print
|
None
|
English
|
| OQA-2430
|
Community Based Residential Facility Residents' Rights Complaint Report*
|
Word - Fillable
|
None
|
English
|
| OQA-2436
|
CBRF Training Program Approval Request-training Block IV Only
|
Paper
|
OQA
|
English
|
| OQA-2436A
|
CBRF Training Program Approval Request-client Group Specific Training
|
Paper
|
OQA
|
English
|
| OQA-2436I
|
Instructions For Completing OQA 2436
|
Paper
|
OQA
|
English
|
| OQA-2445
|
Hospital Annual Report
|
PDF - Print
|
None
|
English
|
| OQA-2447
|
Incident Report of Caregiver Misconduct and Injuries of Unknown Source*
|
PDF - Print
|
None
|
English
|
| OQA-2447
|
Incident Report of Caregiver Misconduct and Injuries of Unknown Source*
|
Word - Fillable
|
None
|
English
|
| OQA-2457
|
Request for Permission to Start Footings, Foundation and/or Demolition
|
PDF - Print
|
None
|
English
|
| OQA-2457
|
Request for Permission to Start Footings, Foundation and/or Demolition
|
Word - Fillable
|
None
|
English
|
| OQA-2461
|
Application For Critical Access Hospital Certification Of Approval
|
Paper
|
OQA
|
English
|
| OQA-2461I
|
Instructions - Application For Critical Access Hospital Certification Of Approval
|
Paper
|
OQA
|
English
|
| OQA-2470
|
Client / Patient Death Determination
|
PDF - Print
|
None
|
English
|
| OQA-2470
|
Client / Patient Death Determination
|
Word - Fillable
|
None
|
English
|
| OQA-2493
|
Referral for Pre-Admission Consultation*
|
PDF - Print
|
None
|
English
|
| OQA-2493
|
Referral for Pre-Admission Consultation*
|
Word - Fillable
|
None
|
English
|
| OQA-2493I
|
Instructions For Referral For Pre-admission
|
Paper
|
OQA
|
English
|
| OQA-2494
|
Health Care Facility Construction Documentation Checklist*
|
PDF - Print
|
None
|
English
|
| OQA-2494
|
Health Care Facility Construction Documentation Checklist*
|
Word - Fillable
|
None
|
English
|
| OQA-2495
|
Compliance Statement*
|
PDF - Print
|
None
|
English
|
| OQA-2495
|
Compliance Statement*
|
Word - Fillable
|
None
|
English
|
| OQA-2496
|
Free-Standing CBRF Plan Approval Application*
|
PDF - Print
|
None
|
English
|
| OQA-2496
|
Free-Standing CBRF Plan Approval Application
|
Word - Fillable
|
None
|
English
|
| OQA-2500
|
Fire Report
|
PDF - Print
|
None
|
English
|
| OQA-2500
|
Fire Report
|
Word - Fillable
|
None
|
English
|
| OQA-2501
|
Laboratory Application for Approval to Perform Alcohol Tests*
|
PDF - Print
|
None
|
English
|
| OQA-2501
|
Laboratory Application for Approval to Perform Alcohol Tests*
|
Word - Fillable
|
None
|
English
|
| OQA-2502
|
Analyst Application to Perform Alcohol Tests*
|
PDF - Print
|
None
|
English
|
| OQA-2502
|
Analyst Application to Perform Alcohol Tests*
|
Word - Fillable
|
None
|
English
|
| OQA-2503
|
Application for Blood / Urine Alcohol Analysis Procedure Approval*
|
PDF - Print
|
None
|
English
|
| OQA-2503
|
Application for Blood / Urine Alcohol Analysis Procedure Approval*
|
Word - Fillable
|
None
|
English
|
| OQA-2504
|
Community Based Substance Abuse Services Or Mental Health Clinic Certification Application
|
PDF - Print
|
None
|
English
|
| OQA-2504
|
Community Based Substance Abuse Services Or Mental Health Clinic Certification Application
|
Word - Fillable
|
None
|
English
|
| OQA-2528
|
Residential Care Apartment Complex Initial Certification or Registration Checklist
|
PDF - Print
|
None
|
English
|
| OQA-2528
|
Residential Care Apartment Complex Initial Certification or Registration Checklist
|
Word - Fillable
|
None
|
English
|
| OQA-2537
|
Petition for Building Code Variance
|
PDF - Print
|
None
|
English
|
| OQA-2537
|
Petition for Building Code Variance
|
Word - Fillable
|
None
|
English
|
| OQA-2546
|
Corporate Guardianship Annual Report*
|
PDF - Print
|
None
|
English
|
| OQA-2546
|
Corporate Guardianship Annual Report*
|
Word - Fillable
|
None
|
English
|
| OQA-2548
|
Assisted Living Facility Request for Waiver, Approval, Variance, Exception*
|
PDF - Print
|
None
|
English
|
| OQA-2548
|
Assisted Living Facility Request for Waiver, Approval, Variance, Exception*
|
Word - Fillable
|
None
|
English
|
| OQA-2569
|
Application for Individual Provider Status Approval*
|
PDF - Print
|
None
|
English
|
| OQA-2569
|
Application for Individual Provider Status Approval*
|
Word - Fillable
|
None
|
English
|
| OQA-2570
|
Supervisor Affidavit*
|
PDF - Print
|
None
|
English
|
| OQA-2570
|
Supervisor Affidavit*
|
Word - Fillable
|
None
|
English
|
| OQA-2579
|
Post Survey Questionnaire*
|
PDF - Print
|
None
|
English
|
| OQA-2579
|
Post Survey Questionnaire*
|
Word - Fillable
|
None
|
English
|
| OQA-2586
|
Challenge Exam Applicant Nurse Aide / Medication Aide*
|
PDF - Print
|
None
|
English
|
| OQA-2586
|
Challenge Exam Applicant Nurse Aide / Medication Aide*
|
Word - Fillable
|
None
|
English
|
| OQA-2588
|
Feeding Assistant Training Program Application
|
PDF - Print
|
None
|
English
|
| OQA-2588
|
Feeding Assistant Training Program Application
|
Word - Fillable
|
None
|
English
|
| OQA-2589
|
Request for Approval to use Telehealth
|
PDF - Print
|
None
|
English
|
| OQA-2589
|
Request for Approval to use Telehealth
|
Word - Fillable
|
None
|
English
|
| OQA-2590
|
Post On-Site Review Questionnaire Nurse Aide Training Programs
|
PDF - Print
|
None
|
English
|
| OQA-2590
|
Post On-Site Review Questionnaire Nurse Aide Training Programs
|
Word - Fillable
|
None
|
English
|
| OQA-2601
|
Rights of Home Health Agency Patients
|
PDF - Print
|
None
|
English
|
| OQA-2601S
|
Derechos De los Pacientes De Un Organismo De Atencion Medica A Domicilio
|
PDF - Print
|
None
|
Spanish
|
| OQA-2603
|
Adult Day Care & Family Day Care Background Character Verification
|
PDF - Print
|
None
|
English
|
| OQA-2603
|
Adult Day Care & Family Day Care Background Character Verification
|
Word - Fillable
|
None
|
English
|
| OQA-2607
|
Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan
|
PDF - Print
|
None
|
English
|
| OQA-2607
|
Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan
|
Word - Fillable
|
None
|
English
|
| OQA-2608
|
Request for Use of Medical Restraints
|
PDF - Print
|
None
|
English
|
| OQA-2608
|
Request for Use of Medical Restraints
|
Word - Fillable
|
None
|
English
|
| OQA-2610
|
Nurse Aide Training Program Primary Instructor Application
|
PDF - Print
|
None
|
English
|
| OQA-2610
|
Nurse Aide Training Program Primary Instructor Application
|
Word - Fillable
|
None
|
English
|
| OQA-2611
|
Family Adult Day Care Certification Standards Checklist
|
PDF - Print
|
None
|
English
|
| OQA-2611
|
Family Adult Day Care Certification Standards Checklist
|
Word - Fillable
|
None
|
English
|
| OQA-2617
|
Alleged Nursing Home Residents Mistreatment, Neglect and Abuse Report
|
PDF - Print
|
None
|
English
|
| OQA-2617
|
Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report
|
Word - Fillable
|
None
|
English
|
| OQA-2643
|
Cancer Drug Repository Program Notice of Participation or Withdrawal
|
PDF - Print
|
None
|
English
|
| OQA-2643
|
Cancer Drug Repository Program Notice of Participation or Withdrawal
|
Word - Fillable
|
None
|
English
|
| OQA-2644
|
Cancer Drug Repository Program Donation, Transfer and Destruction Record
|
PDF - Print
|
None
|
English
|
| OQA-2644
|
Cancer Drug Repository Program Donation, Transfer and Destruction Record
|
Word - Fillable
|
None
|
English
|
| OQA-2645
|
Cancer Drug Repository Program Recipient Record
|
PDF - Print
|
None
|
English
|
| OQA-2645
|
Cancer Drug Repository Program Recipient Record
|
Word - Fillable
|
None
|
English
|
| OQA-2671
|
Adult Family Home Initial Licensure Checklist
|
PDF - Print
|
None
|
English
|
| OQA-2671
|
Adult Family Home Initial Licensure Checklist
|
Word - Fillable
|
None
|
English
|
| OQA-2674
|
Home Health Agency License Application
|
PDF - Print
|
None
|
English
|
| OQA-2674
|
Home Health Agency License Application
|
Word - Fillable
|
None
|
English
|
| OQA-2674A
|
Assisted Living Facility Model Balance Sheet
|
PDF - Print
|
None
|
English
|
| OQA-2674A
|
Assisted Living Facility Model Balance Sheet
|
Word - Fillable
|
None
|
English
|
| OQA-2685
|
Hospital Construction Inspection Questionnaire
|
PDF - Print
|
None
|
English
|
| OQA-2685
|
Hospital Construction Inspection Questionnaire
|
Word - Fillable
|
None
|
English
|
| OQA-9200
|
Ownership And Control Interest Statement
|
Paper
|
Form Center
|
English
|
| OQA-9233
|
Health Insurance Benefit Agreement
|
Paper
|
OQA
|
English
|
| OQA-9248
|
Health Insurance Benefits Agreement
|
Paper
|
OQA
|
English
|
| OQA-9250
|
Ambulatory Surgical Center Request For Certification In The Medicare Program
|
Paper
|
OQA
|
English
|
| OQA-9251
|
Hospice Request For Certification In The Medicare Program
|
Paper
|
OQA
|
English
|
| OQA-9259
|
Long Term Care Facility Application For Medicare And Medicaid Cms671
|
Paper
|
Form Center
|
English
|
| OQA-9260
|
Resident Census And Conditions Of Residents CMS-672
|
Paper
|
Form Center
|
English
|
| OQA-9274
|
Request For Certification As Supplier Of Portable X-ray Services Under The Medicare/Medicaid Program
|
Paper
|
OQA
|
English
|
| OQA-9283
|
Request For Certification In The Medicare And/or Medicaid Program To Provide Outpatient Physical Therapy And/or Speech Pathology Services
|
Paper
|
OQA
|
English
|
| OQA-9284
|
Request To Establish Eligibility To Participate In The Health Insurance For The Aged And Disabled Program To Provide Rural Health Clinic Services
|
Paper
|
OQA
|
English
|
| OQA-9285
|
Consent For Home Visit
|
Paper
|
OQA
|
English
|
| OQA-9305
|
Roster / Sample Matrix
|
Paper
|
Form Center
|
English
|
| OQA-9305A
|
Provider Instructions For HCFA-802
|
Paper
|
OQA
|
English
|
