Ambulatory Care Assessment
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Form # |
Title |
Linked Files |
Instruction/ Comments |
ARR |
Rehabilitative Hospital and Special Hospital subject to a $10 Adjusted Admission Assessment |
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Instructions (pdf 86k)
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HFEL-5 |
Financial Report for Licensed Ambulatory Care Facilities Subject to the Ambulatory Assessment (Updated April 8th, 2024) Submit Online |
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Certificate of Need and Healthcare Facility Licensure
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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 (Last Updated January 31st, 2024) |
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CN-3 |
Application for Certificate of Need for Hospital-Related Projects (Last Updated January 31st, 2024) |
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CN-4 |
Application for Certificate of Need for Designation as a Perinatal Facility (Last Updated January 31st, 2024) |
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CN-6 |
Project Application for an Adult Day Health Services Facility (Formerly HFEL-3) (Last Updated January 31st, 2024) |
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CN-7 |
Application for New or Amended Acute Care Facility License (Last Updated August 16th, 2024) |
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Fees for Licensure and Inspection
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CN-8 |
Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility (Formerly HFEL-4) (Last Updated January 31st, 2024) |
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CN-9 |
Health Care Facility Inquiry Regarding Health Care Professional (HFEL-9) (updated August 10,2017) |
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Instructions (pdf 38k)
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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) (Last Updated January 31st, 2024) |
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CN-28 |
Application for Waiver (Last Updated January 31st, 2024) |
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New fillable PDF form! Word document no longer available.
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HFEL-3 |
Project Application for an Adult Day Health Services Facility (Changed to CN-6, May, 2016) |
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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 |
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Instructions (pdf 12k)
Instructions (doc 23k)
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HFEL-7 |
New Jersey Universal Transfer Form |
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Instructions (pdf 38k)
Instructions (doc 66k)
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LCS-4 |
Communicable Disease Alert |
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LCS-5 |
Application for the Addition of Long-Term Care Beds (Last Updated January 31st, 2024) |
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LCS-8 |
Facility Reporting Incident Data and Analysis Yield (FRIDAY) |
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LCS-9 |
Application for a Long-Term Care Facility License (Last Updated August 16th, 2024) |
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LTC-2 |
Notification form Long-Term Care Facility of Admission or Termination of a Medicaid Beneficiary |
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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) |
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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
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Form # |
Title |
Linked Files |
Instruction/ Comments |
AAS-5 |
Facility Inspection Worksheet (Resident Rights, Physical Plant and Environment, Safety, Dietary Services) |
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AAS-11 |
Nurse Staffing Report (Updated August 5th, 2024) |
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AAS-12 |
Supplementary Nurse Staffing Report (Posted August 5th, 2024) |
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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 |
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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 |
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AAS-84 |
Affidavit of Compliance with N. J. Licensure Standards for Pediatric Medical Day Care Facilities |
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CMP-1 |
Request for Funding from Civil Monetary Penalties (Updated May 29th, 2024) |
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Medication Aide/Nurse Aide Certification Program
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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 (Updated August 8th, 2022) |
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NA-11 |
Addendum: CMA Training - List of Course Attendees (Updated July 8th, 2022) |
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Nursing Home Administrator Licensure and Licensing Board
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Form # |
Title |
Linked Files |
Instruction/ Comments |
NH-1 |
Application for Nursing Home Administrator License (Updated September 1, 2021) |
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NH-5 |
Sponsor Application for Continuing Education Program Approval for Licensed Nursing Home Administrators (Updated January, 2017) |
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Letter to Applicant (pdf 21k)
Letter to Applicant (doc 742k)
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NH-6 |
Request for Reciprocity Verification of Out-of-State Licensure Status (Updated September, 1, 2021) |
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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) |
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NH-10 |
Certification of Program Completion for Nursing Home Administrative Intern Program (Updated September 1, 2021) |
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Surgical Practice Registration
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Form # |
Title |
Linked Files |
Instruction/ Comments |
CN-11 |
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Formerly HFEL-8) (Updated May, 2016) |
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Instructions (pdf 15k)
Instructions (doc 31k)
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HFEL-8 |
Surgical Practice Application for Registration, Renewal, Relocation, Transfer of Ownership (Changed to CN-11, May, 2016) |
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