Committee Minutes – 21st Century Health Care Group

Committee Minutesadmin2017-07-28T16:55:11+00:00

Agency Information

Agency Name *
Agency Address *
Phone Number *
Contact Name *
Contact Phone Number *

Staffing

Administrator *
Administrator Date of Hire *
DON *
DON Date of Hire *
Alternate Administator *
Alternate Administrator Date of Hire *
Alternate DON *
Alternate DON Date of Hire *

Board of Directors/Members and Titles (Note: Members may have more than one title). Minumum of two members.

President *
Vice President *
Secretary *
Treasurer *

Professional Advisory Committee (Name of Therapy company is not acceptable. If you are providing therapies services, individual names must be provided.)

Medical Advisor *Type in N/A if not applicable
Community Representative *Type in N/A if not applicable
Physical Therapy Representative *Type in N/A if not applicable
Speech Therapy Representative *Type in N/A if not applicable
Occupational Therapy Representative *Type in N/A if not applicable
Social Worker Representative *Type in N/A if not applicable
Services to be offered at time of Initial Accreditation and will have the personnel for *

Additional Information

Agency's Hours of Operation *
Date you recieved your initial state license *Type in N/A if not applicable
Date you admitted your 1st Patient (if applicable) *Type in N/A if not applicable
Current Census *Type in N/A if not applicable
Date Medicare Application Accepted *
Accrediting Body *
ACHCCHAP
Which software company are you using?
Type in N/A if not applicable
How did you find us? *

Example: 12
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