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PRINTED: 02/01/2017 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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To fill out Providence Extended Care LTC form, follow these steps:
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Start by providing your personal information, including your name, address, and contact details.
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Specify the type of care you are seeking and provide details about your current health condition.
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Fill in the necessary medical history information, including any existing conditions or medications you are taking.
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Provide information about your insurance coverage, if applicable.
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Include any additional information or preferences you have regarding your care.
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Review the form for accuracy and completeness before submitting it.
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Submit the completed form to the appropriate Providence Extended Care LTC facility.

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Providence Extended Care LTC is a long-term care facility operated by Providence Health & Services.
Providers of long-term care services are required to file Providence Extended Care LTC.
To fill out Providence Extended Care LTC, providers must document patient's medical information, care plans, and medications.
The purpose of Providence Extended Care LTC is to provide quality long-term care services to patients.
Providers must report patient demographics, medical history, medications, and care plans on Providence Extended Care LTC.
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