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Adult Care Home Notice of Transfer/Discharge Mobile App

The Adult Care Home Notice of Transfer/Discharge mobile app is an easy way to send notice of patient transfers using a smartphone or tablet. The app allows you to state the reason for transfer, notification, planned discharge location appeal rights and long term care ombudsman. This app cam be modified to complete mimic your current notice if needed.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Adult Care Home Notice of Transfer/Discharge Mobile App

Included Features

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Included Fields

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

  • Ico date

    DATE OF NOTICE

  • Ico textbox

    Resident Name

  • Ico textbox

    Facility

  • Ico multiline

    Address

  • Ico textbox

    Administrator

  • Ico textbox

    Phone

  • Ico date

    DATE OF TRANSFER/DISCHARGE

  • Ico statictext

    REASON FOR THIS NOTICE

  • Ico statictext

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

  • Ico checkbox

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

  • Ico checkbox

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

  • Ico checkbox

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

  • Ico checkbox

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

  • Ico checkbox

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

  • Ico checkbox

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

  • Ico multiline

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

  • Ico statictext

    NOTIFICATION: In addition to notifying you (i.

  • Ico textbox

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

  • Ico statictext

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

  • Ico multiline

    Name of facility/location

  • Ico multiline

    Name of facility/location

  • Ico textbox

    Phone

  • Ico dropdown

    The facility has convened the adult care home resident discharge team

  • Ico statictext

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

  • Ico statictext

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

  • Ico statictext

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

  • Ico textbox

    Name

  • Ico multiline

    Address

  • ...and More!

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