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Affidavit of Compliance with Licensure Standards for Adult Day Health Care Facilities Mobile App

The Affidavit of Compliance with Licensure Standards for Adult Day Health Care Facilities mobile app was developed to replace your current Adult Affidavit of Compliance with Licensure Standards for Adult Day Health Care Facilities health department paper form. The app can be modified to your states health department’s specifications. You can customize the app yourself, or contact our Sales team to help you at Sales@GoCanvas.com. GoCanvas allows you to do some customization to the standard PDF that is generated when you email or download your submission.

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Take a peek inside the Affidavit of Compliance with Licensure Standards for Adult Day Health Care Facilities Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    I,

  • Ico textbox

    , Administrator of

  • Ico statictext

    , hereby state that to the best of my personal knowledge and understanding, the facility is in su...

  • Ico multiline

    Describe exceptions to compliance:

  • Ico multiline

    I acknowledge that I must provide prompt notification to the Director of Long Term Care Licensing...

  • Ico statictext

    I understand that a willfully false statement could result in enforcement penalties.

  • Ico signature

    Signature of Administrator

  • Ico date

    Date

  • ...and More!

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