WVHCA Model Medical Record Forms Create a streamlined documentation system that is “user friendly,” systematically organized, and provides consistency related to the use of forms. Utilize forms that meet Federal/State survey regulations, reimbursement requirements, and medical/legal issues. The WVLTCSC, through the work of its Model Medical Record Task Force, has developed a series of forms to do all of the above. These forms are available in printed form and on CD. Facilities will receive a one-year license to make unlimited copies of these forms at the license fees given below. There are 67 forms, including the chart order procedure forms, developed by the WVHCA for use in medical record charts in nursing facilities. Note: The Chart Order Form identifies other forms that are recommended as part of a Model Medical Record. These forms must be purchased separately from the appropriate company. Upon receipt of your order form and signed license agreement, we will send you a CD. Please allow 2 to 3 weeks for delivery. Initial One-year License for One Facility WVHCA Member 249.00 Non-member 498.00 Amt Due Sales Tax (7%) Total Due: Price includes shipping and handling Facility: Address: Contact Person: Payment method: Bill my facility (WVHCA Members Only) Credit Card: MC/Visa/AMEx: Expiration: Signature: Phone: Check (Payable to WVLTCSC) West Virginia Long-Term Care Service Corporation 110 Association Drive Charleston, WV 25311 Phone: (304) 346-4575 Fax: (304) 342-0519 Disclaimer: The purpose of the Model Medical Record is to provide long term care facilities with a guide to acceptable practices related to the management of medical records. Before adopting and using the forms, policies or procedures contained in the forms packet, each facility should carefully review these documents and compare them with their own policies, procedures and applicable law. These forms should NOT be construed or relied upon as legal advice.