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					                                                                NURSING ASSISTANT TRAINING AND
                                                                TESTING REIMBURSEMENT FORM
                                                                                                    Office of Rates Management
                                                                           Deliveries and Overnight: 640 Woodland Square Loop, SE, Lacey, WA 98503
                                                                                     Mailing: Post Office Box 45600, Olympia, WA 98504-5600

Provider completes and submits forms quarterly. Reimbursement request must be received 30 days after the end of the quarter.
                                                                                         **Shaded area for DSHS use only**
A. PROVIDER INFORMATION
 1. Provider Name                                                2. Medicaid Reimbursement %                               3. SSPS Number

 4. Contact Person                                               5. Telephone Number                                       6. Vendor Number

 7. Contact Person's FAX Number                                  8. Contact Person's E-mail Address

9. Reimbursement Period (three month period ending): 3/31                             6/30       9/30        12/31       Year:
B. DIRECT CARE COSTS                                                                     Requested Current Costs                  Allowable Current Costs

  1. Cost of staff conducting training
     a. Salaries

     b. Benefits

     c. Payroll Taxes
 2. Less amount charged to other facilities or individuals
     for training
C. OPERATIONS COSTS
  1. Books, materials and supplies provided to nursing
      assistants for training

  2. Fee paid to other institution for training/CPR.
  3. Fee reimbursed to employees for prior testing and
     training
  4. Fee paid for testing nursing assistants
 5. Less amount charged to other facilities or individuals
    for training
D. TOTAL COSTS AND REIMBURSEMENT REQUEST                                                     Current Costs                          Allowable Costs
  1. Total Direct Care Costs                                                         $                            -
  2. Total Operations Costs                                                          $                            -
  3. Total D.1. and D.2.                                   $                                                      -
  4. Request for reimbursement of Medicaid share of costs:                                                                         PAY THIS AMOUNT
                             0%                   =        $                                                      -
                                (round to whole percentage)
E. PROVIDER AUTHORIZATION
I certify under penalty of perjury the items and totals listed are proper charges for materials and services furnished to the nursing assistants, and I have
properly accounted for the proceeds received from individuals and other facilities. I have furnished the materials and services without discrimination on the
grounds of race, creed, color, national origin, sex or age.

 Administrator's signature                                                                                                 Date


F. DEPARTMENT OF SOCIAL AND HEALTH SERVICES (DSHS) AUTHORIZATION
 DSHS Authorizing Signature                                                                                               Date
Nursing Home Name:                                          Vendor Number:                                          SSPS Number:

                                                     NURSING ASSISTANT CERTIFICATION
                                                        INSTRUCTOR INFORMATION
39270
1. Name of Instructor
2. Instructor's social security number.
3. Is instructor employed by facility?
4. Number of hours spent in training. (150 hours is the maximum hours reimbursed per class, per quarter.)
5. Wage - Hourly, monthly salary, etc. Supporting documentation i.e., payroll report identifying worker by name, SSN and verifying wage.
6. Total compensation for salary relating to NAC training this quarter, not including vacation pay or overtime pay.
7. Benefits - anything that is compensation for work done. i.e., insurance, vacation, etc..
8. Payroll taxes.
9. Number of classes conducted this quarter.
10. Start date for each class. List each class on a separate line.
11. End date for each class. List each class on a separate line.
12. Total cost.
13. Less amount charged to other facilities or individuals for training.


          1               2            3            4        5        6        7       8        9        10         11         12           13
        NAME OF         SOCIAL     EMPLOYED      NUMBER     WAGE    WAGE     BENE     PAY   NUMBER      CLASS      CLASS     TOTAL          LESS
    INSTRUCTOR         SECURITY    BY FACILITY    HOURS     PER     FOR      FITS    ROLL      OF       START       END      WAGES     AMT CHG
                       NUMBER         (Y/N)      SPENT IN   HOUR     QTR            TAXES CLASSES       DATE       DATE     BENEFITS        TO
                                                 TRAINING                                                                    TAXES         OTHERS




                                                                                                                                                   Page 2
    1           2           3            4        5      6      7      8       9       10      11       12         13
 NAME OF     SOCIAL     EMPLOYED      NUMBER     WAGE   WAGE   BENE   PAY    NUMBER   CLASS   CLASS    TOTAL      LESS
INSTRUCTOR   SECURITY   BY FACILITY    HOURS     PER    FOR    FITS   ROLL    OF      START   END     WAGES      AMT CHG
             NUMBER        (Y/N)      SPENT IN   HOUR   QTR           TAXES CLASSES   DATE    DATE    BENEFITS     TO
                                      TRAINING                                                         TAXES     OTHERS




                                                                                                                         Page 3
      1            2           3            4        5      6      7      8       9       10      11       12         13
    NAME OF     SOCIAL     EMPLOYED      NUMBER     WAGE   WAGE   BENE   PAY    NUMBER   CLASS   CLASS    TOTAL      LESS
  INSTRUCTOR    SECURITY   BY FACILITY    HOURS     PER    FOR    FITS   ROLL    OF      START   END     WAGES      AMT CHG
                NUMBER        (Y/N)      SPENT IN   HOUR   QTR           TAXES CLASSES   DATE    DATE    BENEFITS     TO
                                         TRAINING                                                         TAXES     OTHERS




     TOTAL




CPR/OTHER INSTITUTIONS




     TOTAL




                                                                                                                            Page 4
Nursing Home Name:                                               Vendor Number:                                           SSPS Number:


                                              NURSING ASSISTANT CERTIFICATION
                                                  STUDENT INFORMATION
1.   Name of Student
2.   Student's social security number
3.   Name of Program where student was trained. i.e., Nursing Facility, Private vocational school, Training Center, College, etc.
4.   Indicate if the student was hired or offered employment or put on a hiring list.
5.   If the student was not hired this quarter, please include the code below which best fits the explanation
     A. Did not Complete Class                  B. Health Reasons                     C. Working at another facility
   D. Disqualified                           E. Nursing School Prerequisite         F. Other (must explain)
6. Amount reimbursed to another facility or vocational school or college, etc.
7. If student paid for and presented a receipt for training/testing, how much was reimbursed?
8. Amount paid for testing by your facility. If student was tested more than once list each testing on a separate line with
   amount paid.
9. Total cost.
                 1                  2               3            4            5               6                 7               8         9
NAME OF STUDENT                   SOCIAL        PROGRAM       OFFERED       IF NOT         AMOUNT            AMOUNT           AMOUNT     TOTAL
                                 SECURITY         WHERE       POSITION     OFFERED      REIMBURSED TO      REIMBURSED          PAID      COST
                                 NUMBER          TRAINED      OR HIRED?    OR HIRED    OTHER INSTITUTION    TO STUDENT          FOR
(Last Name, First Name)                                        (Yes/No)   WHY?(Code)     FOR TRN/TSTG      FOR TRN/TSTG       TESTING




                                                                                                                                         Page 5
                 1           2         3          4            5               6                 7           8        9
NAME OF STUDENT           SOCIAL     PROGRAM   OFFERED       IF NOT         AMOUNT            AMOUNT       AMOUNT    TOTAL
                          SECURITY   WHERE     POSITION     OFFERED      REIMBURSED TO      REIMBURSED      PAID     COST
                          NUMBER     TRAINED   OR HIRED?    OR HIRED    OTHER INSTITUTION   TO STUDENT      FOR
(Last Name, First Name)                         (Yes/No)   WHY?(Code)     FOR TRN/TSTG      FOR TRN/TSTG   TESTING




TOTAL




                                                                                                                     Page 6
Nursing Home Name:                                    Vendor Number:                             SSPS:


                                          NURSING ASSISTANT CERTIFICATION
                                                      SUPPLIES


Any individual item costing more than $750 must be expensed through the cost report/rate process; it cannot be
reimbursed by using this form.

If your facility is conducting nursing assistant training, enter in the amount paid for books, class materials and/or
supplies used as part of your training program for this quarter. Books, class materials and supplies will be
reimbursed according to class size. You must submit receipts to support your reimbursement claim.




         DESCRIPTION OF ITEM             HOW MANY       UNIT COST      TOTAL COST       LESS AMT CHG          ALLOWABLE
                                         REQUESTED                                       TO OTHERS              AMOUNT




                                                                                                                          Page 7
Any individual item costing more than $750 must be expensed through the cost report/rate process; it cannot be
reimbursed by using this form.

If your facility is conducting nursing assistant training, enter in the amount paid for books, class materials and/or
supplies used as part of your training program for this quarter. Books, class materials and supplies will be
reimbursed according to class size. You must submit receipts to support your reimbursement claim.




         DESCRIPTION OF ITEM             HOW MANY       UNIT COST      TOTAL COST       LESS AMT CHG          ALLOWABLE
                                         REQUESTED                                       TO OTHERS              AMOUNT




TOTAL




                                                                                                                          Page 8

				
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