Basic Care Intake Questionnaire

06 Oct Basic Care Intake Questionnaire

This questionnaire complies with section 50-10.2-05 of the North Dakota Century Code. This form is used by the resident to give the facility authorization to contact the county and/or state social services office to obtain information regarding their Medicaid application and eligibility, and approves the release and authorize the county and/or state social services office to release any information to the nursing home.

Click here to open up the form.