# Form 1823

URL: https://pdf.net/pdf-forms/healthcare-forms/form-1823
Category: Healthcare Forms
Attributes: Trusted by accountants, Official IRS form

Form 1823 is a document that must be submitted to establish eligibility for assisted living facilities in Florida.

You’ll find the fillable Form 1823 in our PDF Forms hub, along with information on what it’s for and how to complete it. This makes the entire process far simpler and quicker.

## Versions

- 2021 — [download PDF](https://cdn.sanity.io/files/i16te7yp/production/8beb8ae7f1838ec7f4b0869788f5162f5607220a.pdf)

## How to Fill Out a Form 1823

Step 1: Open Form 1823 in our PDF editor.

Step 2: Fill out resident and facility information.

Step 3: Complete the health assessment section according to the Form 1823 instructions.

Step 4: Add information about the patient’s level of independence, self-care ability, and medication.

Step 5: Fill out details about the medical examiner.

Step 6: Sign the document and keep it in the facility’s records.

## Facts

### What Is the Form 1823?

Form 1823 is a mandatory document used to assess the condition and determine the eligibility of individuals who apply for assisted living facilities in Florida.

### Who Should Use Form 1823?

Form 1823 should be used by licensed healthcare providers, like physicians, their assistants, or registered nurses. This is done after a face-to-face physical exam that assesses the patient’s physical, mental, and cognitive condition.

### When Is the Form 1823 Due?

Form 1823 is due within 60 days before or 30 days after admission to the assisted living facility. Furthermore, examinations must be repeated every three years to meet continued residency criteria, and a new form must be submitted whenever there’s a drastic change in a patient's condition.

### What Are the Penalties For Not Filing the Form 1823?

Penalties for not filing Form 1823 can be significant for the assisted living facility, ranging from $500 to $5,000 a day per violation. In addition, the Florida Agency for Health Care Administration (AHCA) can impose a moratorium on admissions for repeated offenses.

### Where Do I File the Form 1823?

Form 1823 is filed with the assisted living facility where the patient plans to live and is kept on record there.

## Related forms

- [Form CMS-1500](https://pdf.net/pdf-forms/healthcare-forms/cms-1500)
- [DD Form 2870](https://pdf.net/pdf-forms/healthcare-forms/dd-form-2870)
- [Form SSA-3373](https://pdf.net/pdf-forms/healthcare-forms/form-ssa-3373)
- [Form SSA-3441](https://pdf.net/pdf-forms/healthcare-forms/ssa-3441-form)
- [Form N-648](https://pdf.net/pdf-forms/healthcare-forms/form-n-648)