When the number of facilities exceeds the space available on any of the Form 62-761.900(3) parts, or if the provider company prefers to attach a facility list or when this list is amended, we recommend the attachment include the following elements:
A fillable PDF Attachment/Amendment example is available near the top of this page. An MS Word version of the example is available below.
Return to the Financial Assurance Forms (Mechanisms) webpage
Return to the Financial Responsibility General Guidance (FAQs) webpage
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