New Skilled Nursing Facility/Pediatric Forms (SNF/Ped)

Illinois Department of Human Services
Division of Developmental Disabilities
Information Bulletin

New Forms:  Skilled Nursing Facility/Pediatric (SNF/Ped) Forms
August, 2015


This Information Bulletin is to make providers of this service aware of the three finalized new SNF/Ped forms that are to be utilized upon by our providers for these services. These forms were created in collaboration with, and reviewed by, our providers of SNF/Ped Services:

  1. Exceptional Care Program Desk or Waived Quarterly Review Facility Roster  (IL462-0050)
  2. Exceptional Care Program Annual Review Facility Attestation (IL462-0046)
  3. Exceptional Care Program Licensed Labor Cost Analysis (IL462-0049)

Guidelines for Nursing Services Provided

The Division of Developmental Disabilities (DDD) is also including with this Information Bulletin an internal document that is in use by the DDD. These numbers are baseline numbers which will be adjusted secondary to:

  • Review of the individual.
  • Observation of nursing services provided.
  • Recorded documentation.

Please consult the tables in this attached document:  SNF/PED Guidelines for Nursing Services Provided (xls).


If you have any questions or require assistance concerning the above, please contact:

Effective Date

These forms are to be used by our providers upon release of this bulletin.