Skip to content
Call Us Today! 888-850-6932
|
webmaster@21hhc.com
Facebook
Linkedin
Twitter
Youtube
Search for:
Committee Minutes
admin
2017-07-28T16:55:11+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
*
ACHC
CHAP
Which software company are you using?
Type in N/A if not applicable
How did you find us?
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>: