Long Term Care Forms

All documentation containing resident-identifying information must be redacted.

• Assisted Living: IDR Request ODH Form 833AL
• ICF-IID: IDR Request ODH Form 833
• Residential Care: IDR Request ODH Form 833RC
• Skilled Nursing Facilities/Nursing Facilities/Dually-Participating SNF/NF: IDR Request ODH Form 833

• Covered facilities are skilled nursing facilities, nursing facilities, and dually-participating SNF/NF
• All documentation containing resident-identifying information must be redacted
• An IIDR can be requested for deficiencies with a scope and severity of "G" or above that lead to the imposition of a Civil Monetary Penalty (CMP) and for which notice has been provided to the nursing home that the CMP will be collected and placed in escrow
• CMS may collect imposed Civil Monetary Penalties (CMPs) and place them in an escrow account
• You must request the IIDR within 10 calendar days of CMS Initial Imposition Notice

Skilled Nursing Facilities/Nursing Facilities/Dually-Participating SNF/NF: IIDR Request Form 833A