NF Forms and Handbooks

Handbooks

• Denial or Refusal of License
• Licensing Standards for Assisted Living Facilities Handbook
• Licensing Standards for Medication Aides Handbook
• Nursing Facility Administrators Handbook
• Nursing Facility Requirements for Licensure and Medicaid Certification Handbook
• Medicaid Hospice Program Standards Handbook
• Texas Standards for Nurse Aide Registry and Training Handbook

Forms

Authorized Electronic Monitoring Forms (AEM)

• Form 0065 — Information Regarding Authorized Electronic Monitoring for Nursing Facilities (English)
• Form 0065-S — Information Regarding Authorized Electronic Monitoring for Nursing Facilities (Spanish)/a
• Form 0066 — Request for Authorized Electronic Monitoring (English)
• Form 0066-S — Request for Authorized Electronic Monitoring (Spanish)
• Form 0067 — Consent by Roommate for Authorized Electronic Monitoring (English)
• Form 0067-S — Consent by Roommate for Authorized Electronic Monitoring (Spanish)

Capacity Assessment

• Form 2190 — Capacity Assessment for Self-Care and Financial Management

Disclosure Forms

• Form 3641-A — Alzheimer's Nursing Facility Disclosure

Swing Bed Application Forms

• Form 3604 — Ownership Transfer Affidavit

Miscellaneous Forms

• Form 1127 — Fire Marshal/State Fire Marshal Notification
• Form 1129 — Fire Suppression Authority Notification
• Form 2189 — Palliative Care
• Form 3613-A — Provider Investigation Report
• Form 3641-A — Alzheimer's Disclosure Statement for Nursing Facilities
• Form 3645 — Monthly Medicaid Occupancy Report
• Form 3707 — Fire Report for Long Term Care Facilities
• Form 3708 — Amelioration Request
• Form 3726 — Notification of Adverse Change in Financial Condition
• Form 4719 — Fire Drill Report