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FOR OH FUSE LL1 2004 STATE OF ILLINOIS DEPARTMENT OF PUBLIC AID FINANCIAL AND STATISTICAL REPORT FOR LONG-TERM CARE FACILITIES (FISCAL YEAR 2004) I. DPH Facility ID Number: Facility Name: 0026914
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Concord Extended Care-0026914 is a form used to report extended care services provided to patients.
Healthcare providers and facilities offering extended care services are required to file Concord Extended Care-0026914.
Concord Extended Care-0026914 should be filled out accurately and completely with all required information about the extended care services provided.
The purpose of Concord Extended Care-0026914 is to track and report extended care services provided to patients for regulatory and billing purposes.
Information such as patient demographics, dates of service, type of extended care provided, and any relevant notes must be reported on Concord Extended Care-0026914.
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