Providers

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EMAIL: *

DESCRIPTION/SUMMARY:

LICENSE NUMBER: *

BUSINESS ADDRESS: *

AVERAGE MONTHLY COST: *

BUSINESS NAME: *

YEAR BUSINESS OPENED: *

HOUSING TYPE: *

Independent Living

Assisted Living

Memory Care

Adult Family Home

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IS DEPOSIT/COMMUNITY FEE REFUNDABLE:

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CULTURAL/RELIGIOUS SERVICES: *

On-Sight Services Provided

Transportation To Services

No On-Sight Services Provided

Resident Choice

DEPOSIT/COMMUNITY FEE AMOUNT: *

TRANSPORTATION: *

No Transportation Services Available

Assist Coordinating Outside Transportation

Some Transportation Available

Transportation Available Often

SOURCE OF PAYMENT: *

Private Pay Only

Private Pay to Medicaid

Direct Medicaid

I acknowledge the information to be true. *

Yes

VISITING HOURS: *

PROVIDER AGREEMENT:

PROVIDER CELL PHONE: *

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BEHAVIORS YOU WILL NOT ALLOW:

Exit Seeking

Combativeness

Delusions

Hallucinations

BUSINESS PHONE: *

LANGUAGE(S): *

PROVIDER NAME: *

DESCRIPTIONS/SUMMARY: (choose one describing feature from each category below or write in your own description below)

BUSINESS FAX: *

LICENSED TO PROVIDE CARE FOR: *

Dementia

Mental Illness

Developmentally Disabled

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Provider Information Sheet