DAL 16-04: Revised ACF DSS Forms with Assignment of DOH Form Numbers
March 31, 2016
DAL#: 16-04
16-04 Revised ACF DSS Forms with Assignment of DOH Form Numbers
Dear Administrator:
The purpose of this letter is to inform you that the Adult Care Facility forms listed below have been updated with Department of Health (DOH) form numbers. As the forms are referenced in the ACF regulations by their Department of Social Services (DSS) form numbers, the DSS numbers will remain along with the newly assigned doh form numbers. The forms were also revised to include the standard hearding of Adult Care Facility/Assisted Living". The following revised forms are attached:
- Adult Care Facility Daily Resident Census Report
- Adult Care Facility Chronological Admission and Discharge Register
- Notice of Change Enriched Housing Apartment Certification for Residents Receiving Social Security Income (SSI)
- Adult Care Facility Personal Allowance Ledger
- Adult Care Facility Inventory of Resident Property
- Adult Care Facility Statement Offering Personal Allowance Account
- Adult Care Facility Personal Allowance Summary
The Division of ACF/Assisted Living Surveillance will continue to review and update existing forms and notify you of changes. If you have questions regarding the revised forms, please contact the Division of ACF/Assisted Living Surveillance at (518) 408-1133 for further clarificataion.
Sincerely,
Valerie A. Deetz, Director
Division of ACF and Assisted Living Surveillance
Attachments
- Adult Care Facility Daily Resident Census Report (PDF)
- Adult Care Facility Chronological Admission and Discharge Register (PDF)
- Adult Care Facility Personal Allowance Ledger (PDF)
- Adult Care Facility Inventory of Resident Property (PDF)
- Adult Care Facility Statement Offering Personal Allowance Account (PDF)
- Adult Care Facility Personal Allowance Summary (PDF)
