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  • Medicaid Provider Alert: Provider revalidation has begun and those not completing the process risk disenrollment.  Check your account now to learn when your revalidation is due. More information here.
Elizabeth M. Whitehorn, Director

Provider Notice issued 01/20/10

Revised Long Term Care Provider Agreements

To:​

Providers of Nursing Facility and Supportive Living Facility Services​
Date:​ January 20, 2010​
Re:​ Revised Long Term Care Provider Agreements​

As the result of recommendations from the Department of Health and Human Services, Centers for Medicare and Medicaid Services, revisions have been made to Form HFS 1432, Long Term Care Provider Agreement Nursing Facilities (Provider Type 33) (pdf) and Form HFS 1432B, Long Term Care Provider Agreement Supportive Living Facility (Provider Type 28) (pdf).

The revisions comply with federal regulations related to required provider disclosures of ownership and control information, business transaction information and criminal conviction information. To assist with completion of the disclosure information, you may complete Form HFS 1513, Enrollment Disclosure Statement (pdf). This form is available on the department’s Web site.

Nursing facilities and supportive living facilities are instructed to go to the following Web site, complete the applicable provider agreement, print it and return it to the address listed in the instructions located at the top of the provider agreement within ten working days from the date of this notice. 

The provider agreements referenced in this notice are available on the department's Web Site.

Questions can be directed to the Bureau of Long Term Care at 217-524-0372.
 

Theresa A. Eagleson, Administrator

Division of Medical Programs