LTC Applications & Forms

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)
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 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
Hospice/LTC Coordinated Task Plan Form and Instructions
Hospice/LTC Coordinated Task Plan Training Booklet
DA 124A/B - Initial Assessment - Social and Medical - PASRR
DA 124C - Level One Nursing Facility Pre-Admission Screening - PASRR
DA 124C ATT - Notice to Applicant - PASRR
Fire Department Consultation
Fire Report (DA-115)
Guidelines for End-of-Life Care in Long-Term Care Facilities
Guide to Selecting an Alzheimers Special Care Unit
Instructions for Exception Request
Instructions for Second Business Request
Long Term Care Regions Map
Personal Funds Account Balance Report MO 886-3103 (MO 886-3103)
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