Additional Health Department Forms

Forms for Health Facilities, Licensing and Certification

Ambulatory Care Assessment
Form # Form Name/Title Linked File Instruction/ Comments
ARR Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment
pdf (755k)
Instructions (pdf 86k)
 
HFEL-5 Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment
(Updated June 5th, 2023)
Submit Online
HFEL-5 (1349k)
Instructions (779k)  
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
(Last Updated January 31st, 2024)
CN-1 (2582k)
 
CN-3 Application for Certificate of Need for Hospital-Related Projects
(Last Updated January 31st, 2024)
CN-3 (1131k)
 
CN-4 Application for Certificate of Need for Designation as a Perinatal Facility
(Last Updated January 31st, 2024)
CN-4 (1037k)
 
CN-6 Project Application for an Adult Day Health Services Facility
(Formerly HFEL-3)
(Last Updated January 31st, 2024)
CN-6 (219k)
 
CN-7 Application for New or Amended Acute Care Facility License
(Last Updated January 31st, 2024)
CN-7 (1012k)
New fillable PDF form!
Word document no longer available.
Fees for Licensure and Inspection
 
CN-8 Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility
(Formerly HFEL-4)
(Last Updated January 31st, 2024)
CN-8 (206k)
 
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)
(Last Updated January 31st, 2024)
CN-19 (812k)
 
CN-28 Application for Waiver
(Last Updated January 31st, 2024)
CN-28 (184k)
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)
 
HFEL-6 Resident Care Staffing Report
pdf (10k)
doc (29k)
Instructions (pdf 12k)
Instructions (doc 23k)
 
HFEL-7 New Jersey Universal Transfer Form
pdf (21k)
doc (108k)
Instructions (pdf 38k) Instructions (doc 66k)  
LCS-4 Communicable Disease Alert
pdf (10k)
doc (29k)
 
LCS-5 Application for the Addition of Long-Term Care Beds
(Last Updated January 31st, 2024)
LCS-5 (182k)
 
LCS-8 Facility Reporting Incident Data and Analysis Yield (FRIDAY)
pdf (36k)
doc (142k)
 
LCS-9 Application for a Long-Term Care Facility License
(Last Updated January 31st, 2024)
LCS-9 (232k)
 
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  
MH-A1 Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (MH)
pdf (1620k)
 
SUD-A1 Attestation for Compliance with Wavier Requirements to Provide Medications for the Treatment of Substance Use Disorder (SUD)
pdf (1011k)
 
SUD-A2 APPLICATION FOR NEW OR AMENDED RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT FACILITY LICENSE N.J.A.C. 10:161A
doc (242k)
 
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)
pdf (32k)
doc (95k)
 
AAS-11 Nurse Staffing Report
(Updated August 13, 2021)
pdf (284k)
New fillable PDF form!
Word document no longer available.  
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 (1322k)
 
AAS-81 Assisted Living Entrance Guide
pdf (781k)
 
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 (1217k)
 
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-4 (189k)
 
NA-11 Addendum: CMA Training - List of Course Attendees
(Updated July 8th, 2022)
NA-11 (226k)
 
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)
pdf (858k)
 
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) Letter to Applicant (doc 742k)  
NH-6 Request for Reciprocity
Verification of Out-of-State Licensure Status
(Updated September, 1, 2021)
pdf (737k)
 
NH-8 Application for Approval of Administrative Intern Program
(Updated September 1, 2021)
pdf (751k)
 
NH-9 Quarterly Progress Report for
Nursing Home Administrative Intern Program
(Updated September 1, 2021)
pdf (794k)
 
NH-10 Certification of Program Completion for Nursing Home Administrative Intern Program
(Updated September 1, 2021)
pdf (839k)
 
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)
pdf (28k)
doc (127k)
Instructions (pdf 15k)
Instructions (doc 31k)
 
HFEL-8 Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership
(Changed to CN-11, May, 2016)
 
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