Additional Health Department Forms

Forms for Health Facilities, Licensing and Certification

Ambulatory Care Assessment
Form # Title PDF/WORD Instruction/ Comments
HFEL-5 Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment pdf 21k
doc 19k
Instructions
pdf 114k
doc 16k  
Certificate of Need and Healthcare Facility Licensure
Form # Title PDF/WORD Instruction/ Comments
CN-1 Full Review Certificate of Need Application for Long Term Care Facilities: General Long Term Care Beds; Specialized Long Term Care Beds
(Updated December 1, 2016)
pdf 394k
doc 465k
 
CN-3 Application for Certificate of Need for Hospital-Related Projects
(Updated December 1, 2016)
pdf 400k
doc 506k
 
CN-4 Application for Certificate of Need for Designation as a Perinatal Facility
(Updated December 1, 2016)
pdf 276k
doc 205k
 
CN-6 Project Application for an Adult Day Health Services Facility
(Formerly HFEL-3)
(Updated May, 2016)
pdf 16k
doc 41k
 
CN-7 Application for New or Amended Acute Care Facility License pdf 55k
doc 294k
Fees for Licensure and Inspection  
CN-8 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Formerly HFEL-4)
(Updated May, 2016)
pdf 14k
doc 38k
 
CN-9 Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017) pdf 17k
doc 23k
Instructions
pdf 38k  
CN-10 Annual Report of Megavoltage Radiation Unit pdf 17k
doc 60k
 
CN-19 Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a)
(Updated December 1, 2016)
pdf 157k
doc 116k
 
CN-28 Application for Waiver
(Updated December 1, 2016)
pdf 34k
doc 35k
 
HFEL-3 Project Application for an Adult Day Health Services Facility
(Changed to CN-6, May, 2016)
 
 
 
HFEL-4 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Changed to CN-8, May, 2016)
 
 
 
HFEL-6 Resident Care Staffing Report pdf 10k
doc 29k
Instructions
pdf 12k
doc 23k  
HFEL-7 New Jersey Universal Transfer Form pdf 21k
doc 108k
Instructions
pdf 38k
doc 66k  
LCS-4 Communicable Disease Alert pdf 10k
doc 29k
 
LCS-5 Application for the Addition of Long-Term Care Beds
(Updated May, 2016)
pdf 17k
doc 39k
 
LCS-8 Facility Reporting Incident Data and Analysis Yield (FRIDAY) pdf 36k
doc 142k
 
LCS-9 Application for a Long-Term Care Facility License
(Updated May, 2016)
pdf 30k
doc 158k
 
LTC-2 Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary  
 
 
LTC-4 Hospital Preadmission Screening Referral  
 
 
LTC-19 Request for Billing Assistance  
 
 
Health Facility Surveys and Field Operations
Form # Title PDF/WORD Instruction/ Comments
AAS-5 Facility Inspection Worksheet
(Resident Rights, Physical Plant and Environment, Safety, Dietary Services)
pdf 32k
doc 95k
 
AAS-11 Nurse Staffing Report pdf 11k
doc 54k
 
AAS-22 Adult Medical Day Care Inspection Information pdf 31k
doc 73k
 
AAS-23 Pediatric Medical Day Care Inspection Information pdf 25k
doc 62k
 
AAS-24 Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs pdf 19k
doc 74k
 
AAS-40 Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities pdf 14k
doc 42k
 
AAS-45 Reportable Event Record/Report pdf 16k
doc 56k
 
AAS-55 Declaration of Compliance with Advisory Standards pdf 67k
doc 175k
 
AAS-59 Medical Day Inspection Information pdf 29k
doc 77k
 
AAS-60 Consumer Resident/Patient Complaint Report pdf 17k
doc 57k
 
AAS-61 Medical Day Care Assessment and Survey
Exit Conference Guide
pdf 12k
doc 47k
 
AAS-80 Assisted Living Assessment and Survey
Exit Conference Guide
pdf 13k
doc 48k
 
AAS-81 Assisted Living Entrance Guide pdf 8k
doc 23k
 
AAS-84 Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities pdf 13k
doc 39k
 
CMP-1 Request for Funding from Civil Monetary Penalties pdf 174k
doc 473k
 
Medication Aide/Nurse Aide Certification Program
Form # Title PDF/WORD Instruction/ Comments
NA-4 Application for Approval of a Certified Medication Aide Training and Competency Evaluation Program (MATCEP) in Assisted Living Residences / Assisted Living Programs / Comprehensive Personal Care Homes pdf 13k
doc 52k
 
NA-11 Addendum: CMA Training - List of Course Attendees pdf 14k
doc 60k
 
Nursing Home Administrator Licensure and Licensing Board
Form # Title PDF/WORD Instruction/ Comments
NH-1 Application for Nursing Home Administrator License
(Updated May, 2016)
pdf 17k
doc 63k
 
NH-5 Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators
(Updated January, 2017)
pdf 24k
doc 109k
Letter to Applicant
pdf 21k
doc 742k  
NH-6 Request for Reciprocity
Verification of Out-of-State Licensure Status
(Updated May, 2016)
pdf 12k
doc 34k
 
NH-8 Application for Approval of Administrative Intern Program
(Updated May, 2016)
pdf 12k
doc 36k
 
NH-9 Quarterly Progress Report for
Nursing Home Administrative Intern Program
(Updated May, 2016)
pdf 14k
doc 55k
 
NH-10 Certification of Program Completion for Nursing Home Administrative Intern Program
(Updated May, 2016)
pdf 11k
doc 40k
 
Surgical Practice Registration
Form # Title PDF/WORD Instruction/ Comments
CN-11 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8)
(Updated May, 2016)
pdf 28k
doc 127k
Instructions
pdf 15k
doc 31k  
HFEL-8 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership
(Changed to CN-11, May, 2016)
 
 
 
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