Form Snh F1 – Fill Out and Use This PDF

FORM SNH-F1	THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010
Revised 05/26/2010
	STATE HEALTH PLANNING AND DEVELOPMENT AGENCY
MAILING ADDRESS (U.S. Postal Service)		STREET ADDRESS (Commercial Carrier)
PO BOX 303025		100 NORTH UNION STREET STE 870
MONTGOMERY AL 36130-3025		MONTGOMERY AL 36104
TELEPHONE:	(334) 242-4109	FAX: (334) 242-4113
www.shpda.alabama.gov		paul.may@shpda.alabama.gov

2010 ANNUAL REPORT FOR SKILLED NURSING FACILITIES

Mailing Address:

STREET ADDRESSCITYSTATEZIP

Physical Address:

AL

STREET ADDRESS

CITY

ZIP

County of Location:

Facility Telephone:

Facility Fax:

(AREA CODE) & TELEPHONE NUMBER

(AREA CODE) & TELEPHONE NUMBER

This reporting period is for July 1, 2009, through June 30, 2010*; or for partial year of operation beginning

and ending

a period of

days.

MONTH DAY

MONTH DAY

*Data for the agency’s fiscal year, other than the time frame specified, may be provided, but no more than 12 months of consecutive data should be reported. If there was a change in ownership during the reporting period, data for the full year should be reported by the current owner.

We hereby affirm and attest that the reported information has been verified, and to the best of our knowledge, the information contained in the following pages of this report is a true and accurate representation of the services, equipment, and utilization of this facility.

PRINTED NAME OF PREPARER		SIGNATURE OF PREPARER		DATE
DIRECT TELEPHONE NUMBER		TITLE OF PREPARER		E-MAIL ADDRESS

A member of administration MUST also sign below verifying the accuracy of the information contained herein, as reported by the preparer listed above.

PRINTED NAME OF ADMINISTRATION OFFICIAL

SIGNATURE OF ADMINISTRATION OFFICIAL

DATE

DIRECT TELEPHONE NUMBER

TITLE OF ADMINISTRATION OFFICIAL

E-MAIL ADDRESS

FOR OFFICE USE ONLY

Facility Verified:

Initial Scan:

Completed:

Entered:

Final Scan:

Audited:

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FORM SNH-F1	THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010
Revised 05/26/2010
	OWNERSHIP (check one)
Corporation	Non-Profit Organization	Partnership
Individual	Healthcare Authority	LLC
Joint Venture	Government	Other (specify)

Does this facility operate under a management contract? ______ Yes		______	No
Management Firm:	_____________________________________________________________________________
	Name
	_____________________________________________________________________________
	Base Address	City	State	Zip

I.FACILITIES

Skilled Nursing Home

Skilled Nursing Unit of Hospital

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FORM SNH-F1	THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010
Revised 05/26/2010

III.DEMOGRAPHICS

A.TOTAL ADMISSIONS BY RACE FOR THE ENTIRE REPORTING PERIOD

(Total must agree with The totals provided in Section II and Section III-B.)

a.White/Caucasian

b.Black/African American/Negro

c.Hispanic/Spanish/Latino

d.Asian

e.American Indian/Alaskan Native

f.Pacific Islander

g.India

h.Middle Eastern

i. Other (specify)

B.TOTAL ADMISSIONS BY AGE AND GENDER FOR THE ENTIRE REPORTING PERIOD

(Total must agree with the totals provided in Section II and Section III-A.)

AGE GROUPS

MALE

FEMALE

TOTALS

18 & under

19 – 34 Years

35 – 54 Years

55 – 64 Years

65 – 74 Years

75 – 84 Years

85 Years and Older

TOTALS

(Please verify the information provided balances in each row and column)

IV. DISCHARGES

Total discharges (including deaths)

Discharges due to death

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FORM SNH-F1	THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010
Revised 05/26/2010

V.RESIDENT DAYS

(This information is to be provided for the number of individuals in residence during the reporting period.)

OCCUPIED	BED	TOTAL
RESIDENT	HOLDING	RESIDENT
DAYS	DAYS	DAYS

Private Pay

Workman’s Compensation

Medicare

Medicaid

Tricare

Blue Cross (not long term care insurance)

Other Insurance Companies (not long term care

No Charge (charity & other)

Hospice

Long Term Care Insurance

Other (specify) ___________________________

TOTALS

VI. HOSPICE

1.Total hospice service days (regardless of payer source):

2.Number of hospice discharges:

a.Deaths

b.Home

c.Hospital

3.Number of provider contracts:

4. Dedicated hospice unit?

YES NO

5. (If Yes) Number of beds in dedicated hospice unit:

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FORM SNH-F1	THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010
Revised 05/26/2010

VII. EXPENSES & REVENUES (AMOUNTS DO NOT HAVE TO BE AUDITED)

Payroll Expenses		$	.00
Non-Payroll Expenses		$	.00
TOTAL EXPENSES		$	.00
Medicare		$	.00
Medicaid		$	.00
Long Term Care Insurance		$	.00
Hospice		$	.00
Private Pay		$	.00
Other Insurance		$	.00
Other		$	.00
TOTAL REVENUES		$	.00

VIII. CHARGES (rounded off to whole dollars)
BASIC RESIDENT CHARGE		MONTHLY			DAILY
Private Room	$	.00		$	.00
Semi-Private Room	$	.00		$	.00

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