Facilities Case Mix Forms

A Case Mix Form has been created for each Facility to use for Case Mix submissions.  By clicking on the link below you will find your Facility's Case Mix Form.  Download the Case Mix Form from this website, complete with required information, and submit the Form through the electronic process using your GlobalScape account.

Facility Case Mix Forms



Contact Us

Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury, VT 05671-2060
(802) 241-0344

For Telecommunications Relay Service: Dial 711

Adult Protective Services Reporting Line
(800) 564-1612

Healthcare Organization Complaint Reporting Line
(888) 700-5330

Joe Nusbaum
Division Director

John Gordon
Adult Protective Services Director

Suzanne Leavitt
Survey and Certification Director


This is a Division of the
Department of Disabilities, Aging and Independent Living
under the Agency of Human Services