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| Group | Provider Type | Template Name in pdf format | Template Name in Word format |
|---|---|---|---|
| Independent |
Hospital Critical Access Hospital |
CMS Compliant HVA and Templates
Which template should my facility use?
The table below provides guidance regarding which template to use for each industry.
| Group | Provider Type | Template Name in pdf format | Template Name in Word format |
| Independent | Hospital | Inpatient Facility Plan Template | Inpatient Facility Plan Template |
| Critical Access Hospital | Inpatient Facility Plan Template | Inpatient Facility Plan Template | |
| Long Term Care Facility | Inpatient Facility Plan Template | Inpatient Facility Plan Template | |
| Psychiatric Residential Treatment Facility (PRTF) | Inpatient Facility Plan Template | Inpatient Facility Plan Template | |
| Intermediate Care FAcility for Individuals with Intellectual Disabilities (ICF/IID) | Inpatient Facility Plan Template | Inpatient Facility Plan Template | |
| Religious NonHealthcare Institution (RNHCI) | No RNHCI in Louisiana | NO RHNCI in Louisiana | |
| Transplant Center (are embedded in a HOSPITAL) | Inpatient Facility Plan Template | Inpatient Facility Plan Template | |
| Outpatient | Hospice | Hospice Plan Template | Hospice Plan Template |
| Ambulatory Surgical Center | ASC Plan Template | ASC Plan Template | |
| Program for the All-Inclusive Care of the Elderly (PACE) | PACE Plan Template | PACE Plan Template | |
| Home Health Agency | Home Health Plan Template | Home Health Plan Template | |
| Comprehensive Outpatient Rehabilitation Facility (CORF) | CORF Plan Template | CORF Plan Template | |
| Community Mental Health Center (CMHC) | CMHC Plan Template | CMHC Plan Template | |
| Organ Procurement Organization (OPO) | OPO Plan Template | OPO Plan Template | |
| Clinics, Rehabilitation, and Therapy | Clinic Plan Template | Clinic Plan Template | |
| Rural Health Clinic (RHC)/ Federal Qualified Health Center (FQHC) | RHC FQHC Plan Template | RHC FQHC Plan Template | |
| End Stage Renal Disease (ESRD) | ESRD Plan Template | ESRD Plan Template |