Ambulatory Care Assessment
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| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| ARR |
Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment |
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| HFEL-5 |
Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment
(Last edited April 19, 2022)
Submit Online |
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Instructions (745k)
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Certificate of Need and Healthcare Facility Licensure
|
| Form # |
Form Name/Title |
Linked File |
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) |
|
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| CN-3 |
Application for Certificate of Need for Hospital-Related Projects
(Updated December 1, 2016) |
|
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| CN-4 |
Application for Certificate of Need for Designation as a Perinatal Facility
(Updated December 1, 2016) |
|
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| CN-6 |
Project Application for an Adult Day Health Services Facility
(Formerly HFEL-3)
(Updated May, 2016) |
|
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| CN-7 |
Application for New or Amended Acute Care Facility License
(Last Updated November 10th, 2021) |
|
New fillable PDF form!
Word document no longer available.
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| CN-8 |
Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Formerly HFEL-4)
(Updated May, 2016) |
|
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| CN-9 |
Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017) |
|
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| CN-10 |
Annual Report of Megavoltage Radiation Unit |
|
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| CN-19 |
Certificate of Need Application-Expedited Review for Facilities and Services Identified at NJAC 8:33-5.1(a)
(Updated December 1, 2016) |
|
|
| CN-28 |
Application for Waiver
(Updated November 3rd, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
| 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) |
|
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| HFEL-6 |
Resident Care Staffing Report |
|
|
| HFEL-7 |
New Jersey Universal Transfer Form |
|
Instructions (pdf 38k)
Instructions (doc 66k)
|
| LCS-4 |
Communicable Disease Alert |
|
|
| LCS-5 |
Application for the Addition of Long-Term Care Beds
(Updated May, 2016) |
|
|
| LCS-8 |
Facility Reporting Incident Data and Analysis Yield (FRIDAY) |
|
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| LCS-9 |
Application for a Long-Term Care Facility License
(Updated May 23, 2022) |
|
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| LTC-2 |
Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary |
|
|
| LTC-4 |
Hospital Preadmission Screening Referral |
|
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| LTC-19 |
Request for Billing Assistance |
|
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| MH-A1 |
Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH) |
|
|
| SUD-A1 |
Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD) |
|
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| SUD-A2 |
APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. 10:161A |
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Health Facility Surveys and Field Operations
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| AAS-5 |
Facility Inspection Worksheet
(Resident Rights, Physical Plant and Environment, Safety, Dietary Services) |
|
|
| AAS-11 |
Nurse Staffing Report
(Updated August 13, 2021) |
|
New fillable PDF form!
Word document no longer available.
|
| AAS-22 |
Adult Medical Day Care Inspection Information |
|
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| AAS-23 |
Pediatric Medical Day Care Inspection Information |
|
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| AAS-24 |
Affidavit of Compliance Assisted Living Residences, Comprehensive Personal Care Homes and Assisted Living Programs |
|
|
| AAS-40 |
Affidavit of Compliance with N. J. Licensure Standards for Adult Day Health Care Facilities |
|
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| AAS-45 |
Reportable Event Record/Report |
|
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| AAS-55 |
Declaration of Compliance with Advisory Standards |
|
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| AAS-59 |
Medical Day Inspection Information |
|
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| AAS-60 |
Consumer Resident/Patient Complaint Report |
|
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| AAS-61 |
Medical Day Care Assessment and Survey
Exit Conference Guide |
|
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| AAS-80 |
Assisted Living Assessment and Survey
Exit Conference Guide |
|
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| AAS-81 |
Assisted Living Entrance Guide |
|
|
| AAS-84 |
Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities |
|
|
| CMP-1 |
Request for Funding from Civil Monetary Penalties |
|
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Medication Aide/Nurse Aide Certification Program
|
| Form # |
Form Name/Title |
Linked File |
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
(Updated August 8th, 2022) |
|
|
| NA-11 |
Addendum: CMA Training - List of Course Attendees
(Updated July 8th, 2022) |
|
|
Nursing Home Administrator Licensure and Licensing Board
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| NH-1 |
Application for Nursing Home Administrator License
(Updated September 1, 2021) |
|
|
| NH-5 |
Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators
(Updated January, 2017) |
|
Letter to Applicant (pdf 21k)
Letter to Applicant (doc 742k)
|
| NH-6 |
Request for Reciprocity
Verification of Out-of-State Licensure Status
(Updated September, 1, 2021) |
|
|
| NH-8 |
Application for Approval of Administrative Intern Program
(Updated September 1, 2021) |
|
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| NH-9 |
Quarterly Progress Report for
Nursing Home Administrative Intern Program
(Updated September 1, 2021) |
|
|
| NH-10 |
Certification of Program Completion for Nursing Home Administrative Intern Program
(Updated September 1, 2021) |
|
|
Surgical Practice Registration
|
| Form # |
Form Name/Title |
Linked File |
Instruction/ Comments |
| CN-11 |
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8)
(Updated May, 2016) |
|
|
| HFEL-8 |
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership
(Changed to CN-11, May, 2016) |
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