Less Than 30 Day Move-Out Notice Template Page 2
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2If you object to this move based on the reasons stated in this notice:
You have five (5) working days to request an administrative hearing after receipt of
this notice by completing the attached Hearing Request Form (DHS 0443).
SPD may hold an informal meeting to resolve this matter. If you are satisfied with
the outcome of this meeting, then no administrative hearing will be held.
Hearings are held before an administrative law judge who works for the Office of
Administrative Hearings.
You can have a lawyer or someone else help you if a hearing is held. You may
be able to obtain free legal services through the local legal aid office or the
bar association.
Note to military personnel: Active duty service members have a right to stay
these proceedings under the federal Service members Civil Relief Act. For more
information, you may contact the Oregon State Bar (800-452-8260), the Oregon
Military Department (800-452-7500), or the nearest legal assistance office,
If you are having difficulty understanding this notice, your rights, or if you need an
advocate, the Long-Term Care Ombudsman Office can help you. You can contact
them at:
Office of the Long-Term Care Ombudsman
3855 Wolverine NE, Suite 6
Salem, OR 97305-1251
Telephone: 1-800-522-2602 or TTY: 1-503-378-5834
Copies of this notice have also been issued to the following people and agencies:
Name and relationship
Address and phone number
Signature and title of facility representative
Date
This notice is being issued pursuant to Oregon Administrative Rule 411-054-0080(6)(a-c)
A copy of this notice must be faxed to the Office of Licensing and Regulatory
Oversight at 503-378-8966, or emailed to:
CBC.Team@dhsoha.state.or.us
and to
the Long-Term Care Ombudsman Office at 503-373-0852 on the same day it is
delivered to the resident.
Page 2 of 2
SDS 0568 (01/2015)
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