LTC Applications & Forms
Online Payments
Application for License to Operate a Long-Term Care Facility
DA-150 Application for License to Operate a Long Term Care Facility (MO 580-2631)
DA-637 Assurance of Compliance (MO 580-2622)
Principal List (MO 580-2925)
DA-635 Affiliate List - Corporation (MO 580-2626)
DA-632 Affiliate List - Limited Liability Company (LLC) (MO580-2630)
DA-633 Affiliate List - Nonprofit Corporation (MO 580-2627)
DA-634 Affiliate List - Partnership (MO 580-2629)
DA-150d Relicensure Financial Information Statement - General (MO 580-2633)
DA 150c Relicensure Financial Information Statement - Sole Proprietor (MO 580-2634)
DA-150a Statement of Financial Condition - Sole Proprietor (MO 580-2632)
DA-150e Statement of Financial Position - General (MO 580-2635)
DA-150b Forecasted Income Statement - All Operators (MO 580-2636)
DA-639 Noncancelable Escrow Agreement (MO 580-2628)
DA-638 Nursing Home Surety Bond (MO 580-2624)
DA-621 Alzheimer's Special Care Services Disclosure (MO 580-2637)
Alzheimer's Disclosure Form Check Sheet
DA-636 Corrections for Long Term Care Facility License Application (MO 580-2623)
Application for License to Operate an Adult Day Care Program
Application for License to Operate an Adult Day Care Program
Alzheimer's Disclosure Form Check Sheet
Alzheimer's Special Care Services Disclosure Form
Other Long Term Care Resources
Application for Registration as a Qualified Receiver for a Long-Term Care Facility
Background Checks - A Guide for Long Term Care Facilities
Bed Listing for Licensure and Certification
Certification of Electric Wiring
Change of Administrator-Manager in a Long-Term Care Facility
Change of Director of Nursing in a Long-Term Care Facility
Compassionate Care Visitation Guidance
Electronic Monitoring Device Acknowledgement and Request Form
Hospice/LTC Coordinated Task Plan Form and Instructions
Hospice/LTC Coordinated Task Plan Training Booklet
Facility Reported Incidents - Initial Reporting Form
Fire Department Consultation
Fire Report (DA-115)
Follow-up Investigation Form
Guidelines for End-of-Life Care in Long-Term Care Facilities
Guide to Selecting an Alzheimers Special Care Unit
Instructions for Exception Request (updated 02/10/23)
Instructions for Second Business Request (updated 02/10/23)
Long Term Care Regions Map
PASRR
Personal Funds Account Balance Report
Potluck Dinners, Barbeques, Fish Fries, Garden Produce & Other Good Things
Pre-Screening and Assessment for Admission to Assisted Living Facilities
Resident Care Survey - RCF /ALF
Resident Care Survey - ICF/SNF