Nursing Home Dispute Resolution

Asterisk (*) Indicates required field

Select your 5-digit HFID Code

Which dispute resolution process are you requesting?

IDR

Independent IIDR (Select only if you have already received a Civil Money Penalty.)

What is the Exit Date of the survey being disputed:

Please identify the deficiencies you are disputing by tag number (e.g., F689, K345):

Please briefly describe the reasons the facility is disputing the tag(s)

Is the facility represented by an attorney?

Yes

Please provide the attorney’s contact information:

Attorney's Name

Attorney's Email

Attorney's Phone

Do you want a prehearing conference?

Yes

Please identify dates within the next 10 days you are available for a prehearing:

Please identify dates within the next 60 days you are available for the Independent IDR proceeding:

Please identify dates within the next 21-35 days that you are available for the Independent IIDR proceeding:

Submitter Name

Submitter Email

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