Maintenance of Self-declared Provider Records 620-01-55-05

(Revised 1/1/14 ML #3393)

View Archives

 

 

Authorized agent and regional office must maintain the following records for each self-declared provider:

 

• Self-declaration document, SFN 865

 

• Copies of CPR/First Aid card, if applicable

 

• Documentation of SFN 1595 for pre-approval visit and unannounced visits

 

• Documentation of concerns and correction, if applicable

 

• SFN 508 emergency designee and new household members

 

• Copy of required training certificate

 

• Copy of pet vaccinations