Adult Care Home Notice of Transfer/Discharge Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  DATE OF NOTICE

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  Resident Name

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  Facility

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  Address

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  Administrator

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  Phone

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  DATE OF TRANSFER/DISCHARGE

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  REASON FOR THIS NOTICE

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  Under (State) rules and regulations, you may only be transferred or discharged from this facility...

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  It is necessary for your welfare and your needs cannot be met in this facility as documented by t...

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  Your health has improved sufficiently so that you no longer need the services provided by this fa...

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  The safety of the resident or other individuals in this facility is endangered;

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  The health of the resident or other individuals in this facility is endangered as documented by a...

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  You have failed to pay the cost of services and accommodations by the payment due date specified ...

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  The discharge is mandated under (State Rule) or rules adopted by the Medical Care Commission.

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  The reason for this notice of your transfer/discharge is:

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  NOTIFICATION: In addition to notifying you (i.

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  (Responsible person or contact person) has also been notified.

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  PLANNED DISCHARGE LOCATION: This facility plans to transfer/discharge you to

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  Name of facility/location

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  Name of facility/location

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  Phone

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  The facility has convened the adult care home resident discharge team

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  APPEAL RIGHTS: You have the right to appeal this transfer/discharge if you disagree with the reas...

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  [Note: if a discharge is initiated due to “it is necessary for your welfare and your needs cannot...

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  LONG TERM CARE OMBUDSMAN: You may wish to contact your regional long term care ombudsman for help...

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  Name

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  Address

• ...and More!