Form Hea 7713 PDF Details

The State of Ohio Department of Health, through its Office of Health Assurance and Licensing, mandates the use of the Nurse Aide Registration Form, known as HEA 7713. This essential document plays a pivotal role in ensuring that nurse aides in the state maintain their active status and remain in good standing on the Ohio Nurse Aide Registry. The form requires facilities to report accurately and comprehensively the employment details of nurse aides, including those contracted through temporary staffing agencies. Specifically, it requires that these aides have provided at least 7.5 consecutive hours or 8 hours of nursing or nursing-related services within a 48-hour period in the last 24 months, a criterion necessary for re-registration. The form also emphasizes the necessity of providing precise data regarding the last date the nurse aide was utilized, prohibiting the use of the term "current" or leaving this field blank. This requirement underscores the importance of accurate record-keeping in avoiding the expiration of a nurse aide's registration due to incomplete or inaccurate data submission. Available for download from the Ohio Department of Health's website, this form facilitates communication between health facilities and the Nurse Aide Registry, ensuring that nurse aides meet the state's standards for employment in healthcare settings. Additionally, if a facility is not Medicare certified, the registry demands a supplementary statement from a physician or nurse verifying the aide's provision of care, further highlighting the rigorous standards upheld by the Ohio Department of Health to ensure quality care across the state.

QuestionAnswer
Form NameForm Hea 7713
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesohio hea registration form, hea 7713 form download, ohio nurse aide registration form, ohio aide form printable

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State of Ohio

Department of Health

Office of Health Assurance and Licensing

Nurse Aide Registration Form (HEA 7713)

This form gives the Ohio Nurse Aide Registry the required information necessary to update nurse aides’ employment so they will remain active and in good standing on the Ohio Nurse Aide Registry.

In order for the nurse aides included in this document to be re-registered, they must have provided for compensation, nursing or nursing-related services for at least 7.5 consecutive hours or 8 hours in a 48-hour period, all within the last 24 months.

Instructions for Use:

List all nurse aides used by the facility since the last survey that meet the above criteria, including aides through temporary staffing services.

The definition of “Last Date Used” is the last date the nurse aide worked as an aide in your facility. In the “Last Date Used” box, do not use the word “current” or leave” blank” when completing the form. The word “current”

or a blank space does not accurately reflect the last date the nurse aide was used as a nurse aide or the last date the nurse aide was employed by your facility. Failure to complete this form accurately will cause the nurse aides’ information to reflect inaccurate data and may possibly cause the nurse aides’ registration to expire. Incomplete forms will be returned for correction.

Forms are available online at the Ohio Department of Health website: www.odh.ohio.gov

Contact the Nurse Aide Registry by phone at (800) 582-5908 (in state only); or (614) 752-9500; by fax at (614) 564- 2461; or by e-mail at NAR@odh.ohio.gov. The Nurse Aide Registry is accessible online at http://www.odh.ohio.gov/odhPrograms/io/nurseaide/nurseaide1.aspx

NOTE: If your facility is not Medicare certified, the Registry will return the completed HEA 7713 and request that the following statement is returned with completed HEA 7713 form. Ohio Administrative Code OAC 3701-17-07.1 (C)(1)

1.A statement by a physician or nurse verifying that he or she has personal knowledge that the individual provided nursing and nursing-related services to a patient under the physician's or nurse's care. The statement shall further verify:

OThe name of the individual that provided nursing and nursing-related services for such patient;

OThe nature of the nursing and nursing-related services and the date or dates the individual last provided seven and one-half consecutive hours or eight hours in a forty-eight hour period of nursing and nursing related services;

OThat the individual received compensation for the services specified in paragraph (D)(2)(b) of this rule. If the physician or nurse is unable to verify that the individual was compensated for those services, the individual must provide further proof that he or she received compensation for the specified services.

HEA 7713 (Rev. 04/24/15)

State of Ohio

Department of Health

Office of Health Assurance and Licensing

Nurse Aide Registration Form (Facility)

Section I (Facility Information)

Facility Name:

 

 

 

 

 

 

 

Facility Medicare Number: (i.e. 36 _ _ _ _)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

County:

 

 

 

 

 

State:

 

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

FAX:

 

Name of Person to Contact:

 

 

 

 

 

 

 

 

 

 

 

Email (s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Facility:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

฀ Nursing Home

฀ Hospital

฀ RCF

 

 

 

 

฀ Home Health Agency

฀ Hospice

฀ ACF

 

 

 

 

฀ ICF/MR

฀ Staffing Agency

฀ Other (please describe)_________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Home Administrator:

 

 

License Number:

 

 

 

Name of Director of Nursing:

 

 

License Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Home Administrator:

 

 

 

 

 

 

 

Signature of Director of Nursing:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II (Nurse Aide Information)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List ALL nurse aides used by the facility, including aides used through temporary staffing services:

 

 

 

 

Name (Last, First, MI):

 

 

 

 

 

 

 

 

 

 

NAR Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

County:

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

 

 

 

 

 

 

 

 

NAR Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

County:

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

 

 

 

 

 

 

 

 

NAR Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

County:

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

 

 

 

 

 

 

 

 

NAR Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

County:

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEA 7713 (Rev. 04/24/2015)

Nurse Aide Registration Form (Facility) (Continued)

Section II (Nurse Aide Information)

List ALL nurse aides used by the facility, including aides used through temporary staffing services:

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

Name (Last, First, MI):

NAR Number

Street Address:

Date of Hire:

Last Date Used:

City:

County:

State:

ZIP:

HEA 7713 (Rev. 04/24/2015)

Nurse Aide Registration Form (Facility) (Continued)

Section II (Nurse Aide Information)

List ALL nurse aides used by the facility, including aides used through temporary staffing services:

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

Name (Last, First, MI):

NAR Number

Street Address:

Date of Hire:

Last Date Used:

City:

County:

State:

ZIP:

HEA 7713 (Rev. 04/24/2015)

Nurse Aide Registration Form (Facility) (Continued)

Section II (Nurse Aide Information)

List ALL nurse aides used by the facility, including aides used through temporary staffing services:

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

Name (Last, First, MI):

NAR Number

Street Address:

Date of Hire:

Last Date Used:

City:

County:

State:

ZIP:

HEA 7713 (Rev. 04/24/2015)

Nurse Aide Registration Form (Facility) (Continued)

Section II (Nurse Aide Information)

List ALL nurse aides used by the facility, including aides used through temporary staffing services:

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

Name (Last, First, MI):

 

 

NAR Number

 

 

 

 

 

 

Street Address:

 

Date of Hire:

Last Date Used:

 

 

 

 

 

 

City:

County:

State:

ZIP:

 

 

 

 

 

Name (Last, First, MI):

NAR Number

Street Address:

Date of Hire:

Last Date Used:

City:

County:

State:

ZIP:

HEA 7713 (Rev. 04/24/2015)

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Filling out section 1 of ohio aide form printable

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Hospital Hospice Staffing Agency, RCF ACF Other please describe, and Name of Director of Nursing of ohio aide form printable

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