Form 3643 PDF Details

The Form 3643, also known as the Employer Federal Tax Identification Number (EIN) application, is a document used to apply for an Employer Identification Number (EIN). The EIN is a nine-digit number that is issued by the IRS and identifies a business entity. The form can be filed online or by mail, and it takes about four weeks for the IRS to process the application. There are a few things to keep in mind when filing for an EIN, such as ensuring all information is accurate and up-to-date. It's important to remember that the EIN is not only used for federal tax purposes, but also for other important tasks such as opening a bank account or filing state taxes.

If you want to first find out how much time you need to fill in the form 3643 and the number of pages it's got, here is some general data that will be of use.

QuestionAnswer
Form NameForm 3643
Form Length2 pages
Fillable?Yes
Fillable fields232
Avg. time to fill out23 min 29 sec
Other namesrestorative nursing program forms, texas form 3643 department, form nursing restorative care form, texas nursing restorative care program

Form Preview Example

Texas Department of Aging

and Disability Services

Discipline

 

 

Month and Year of Service

PT

OT

ST

 

 

 

 

 

SECTION I – PLAN OF CARE

Form 3643

November 1996

NURSING RESTORATIVE CARE PROGRAM

Goals

1.

2.

3.

4.

Approaches (with frequency)

Date Restorative Initiated

1.

2.

3.

4.

5.

Signature–RN

 

Signature–Therapist

Signature–Therapist

 

 

 

 

SECTION II – APPROACHES:

W=Withheld

R=Refused D=Discharged

Document in Weekly Notes the reason if “Withheld” or “Refused.”

APPROACHES

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26 27 28 29 30 31

Approach #1

Approach #2

Approach #3

Approach #4

Approach #5

NOTE: Each person who initials the approaches (above) must initial and sign below.

Initials

 

Signature

 

Initials

 

Signature

 

Initials

 

Signature

 

 

 

 

 

 

 

 

 

 

 

Initials

 

Signature

 

Initials

 

Signature

 

Initials

 

Signature

Resident Name:

 

Room No.:

Form 3643

Page 2

SECTION III – DOCUMENT RESIDENT’S RESPONSE AND PROGRESS TOWARD GOALS(S):

Week 1 – Response

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 2 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 3 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 4 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

Week 5 – Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

Date

SECTION IV – MONTHLY REVIEW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Is the Plan of Care appropriate?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

B. Are changes to the Restorative Program recommended?

 

 

 

 

 

 

 

Yes

No

 

Are changes recommended to the Goals?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

Are changes recommended to the Approaches?

 

 

 

 

 

 

 

 

 

Yes

No

 

If YES to any items in B, update next month’s SECTION I–PLAN OF CARE with the changes.

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Continue Program?

 

 

Yes

No

D. Discharge to basic nursing?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature–Licensed Staff

 

 

 

Date

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texas form 3643 department aging fields to consider

Write the demanded details in the APPROACHES, Approach #1, Approach #2, Approach #3, Approach #4, Approach #5, NOTE: Each person who initials the, Initials, Initials, Signature, Signature, Initials, Initials, Signature, Signature, Initials, Initials, Signature, Signature, Resident Name:, and Room No segment.

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Note down the required information since you are within the Week 1 – Response, Week 2 – Response, Week 3 – Response, Signature, Signature, Date, and Date segment.

Completing texas form 3643 department aging part 3

Spell out the rights and obligations of the parties in the box Week 4 – Response, Week 5 – Response, Signature, Signature, SECTION IV – MONTHLY REVIEW, Is the Plan of Care appropriate, Are changes recommended to the, Are changes recommended to the, Date, Date, Yes, Yes, Yes, and Yes.

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Finalize by reviewing the next fields and writing the relevant particulars: Comments:, Yes, Yes, Signature–Licensed Staff, and Date.

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