Ambulatory Care Assessment
Form # Title Linked Files 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
(Last edited April 19, 2022)
Submit Online
HFEL-5 (1340k)
Instructions (745k)  

Certificate of Need and Healthcare Facility Licensure
Form # Title Linked Files 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
(Last Updated November 10th, 2021)
pdf (421k)
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)
(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 November 3rd, 2021)
pdf (168k)
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
(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 23, 2022)
pdf (30k)
 
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 # Title Linked Files 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 # Title Linked Files 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 Linked Files 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 # Title Linked Files 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)