A0050

Type of Record

x Applies ›

X0150

Type of Provider (A0200 on existing record to be

x Applies ›

X0200

Name of Resident (A0500 on existing record to be

x Applies ›

X0310

Sex (A0810 on existing record to be modified/inactivated)

x Applies ›

X0400

Birth Date (A0900 on existing record to be

x Applies ›

X0500

Social Security Number (A0600A on existing record to be

x Applies ›

X0600

Type of Assessment/Tracking (A0310 on existing record

x Applies ›

X0700

Date on Existing Record to Be Modified/Inactivated –

x Applies ›

X0800

Correction Attestation Section

x Applies ›

X0900

Reasons for Modification

x Applies ›

X1050

Reasons for Inactivation

x Applies ›

X1100

RN Assessment Coordinator Attestation of Completion

x Applies ›

Z0400

Signatures of Persons Completing the Assessment or

- Not submitted to iQIES ›