Less Than 30 Day Move-Out Notice Template
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Residential Care and Assisted Living Facilities
LESS THAN 30 DAY MOVE-OUT NOTICE
Notice issued to: Last name:
First name:
Date issued:
/
/
Date of proposed move-out:
/
/
Name of facility:
RCF
ALF
MCC
Address:
City/state/ZIP:
Telephone:
Fax:
This move-out notice is being issued for:
Medical/psychiatric care: You have left the facility to receive urgent medical or
A.
psychiatric care. You have been evaluated by an appropriate staff person from
the facility. The facility has determined your current health or service needs
cannot be met by the facility (see description below). You have the right to an
administrative hearing. If you request an administrative hearing, the facility
must hold your room and may charge room and board pending resolution of
the hearing.
The specific needs that cannot be met are:
B.
Health and safety reasons: The facility has determined that your health and
safety, or the health and safety of other residents, is in jeopardy and undue delay
in moving would increase the risk of harm to yourself and others, as indicated in
the description below. You have the right to an administrative hearing. If you
request an administrative hearing, the facility must hold your room without
charging for room and board or services pending resolution of the hearing.
(FACILITY NOTE: Your Salem Central Office Policy Analyst must be
contacted prior to giving this notice to a resident that is still in the facility.)
The specific health and safety concerns are:
If you object to this move based on the reasons stated in this notice:
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SDS 0568 (01/2015)
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Parent category: Legal