Form Dma-9050 - Notice Of Transfer/discharge
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NURSING HOME
NOTICE OF TRANSFER/DISCHARGE
1)
DATE OF NOTICE: _____________________
2)
RESIDENT:
_________________________________________
FACILITY:
______________________________________________________________________
ADDRESS:
______________________________________________________________________
ADMINISTRATOR:
_______________________________ PHONE: _________________________
3)
DATE OF TRANSFER/DISCHARGE: ___________________________________________
Under federal law (42 U.S.C 1396r(c)(2)(A); 42 CFR 483.12), you may only be transferred or discharged from this nursing
facility for one of the following reasons:
It is necessary for your welfare and your needs cannot be met in this facility;
Your health has improved sufficiently so that you no longer need the services provided by this facility;
The safety of individuals in this facility is endangered;
The health of individuals in this facility would otherwise be endangered;
You have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay
at this facility; or
The facility ceases to operate.
4)
THE REASON FOR THIS NOTICE OF YOUR TRANSFER/DISCHARGE IS: ___________________
___________________________________________________________________________________________
5)
In addition to notifying you (i.e. the resident) of this transfer/discharge, _______________________________
has also
been notified.
(family member/legal representative)
6)
Check ONE and INDICATE LOCATION below:
{ }
THIS FACILITY PLANS TO TRANSFER YOU TO:
{ }
THIS FACILITY PLANS TO DISCHARGE YOU TO:
NAME OF FACILITY/LOCATION: ___________________________________________________________________
ADDRESS: ____________________________________________________
PHONE: ________________________
You have the RIGHT TO APPEAL this transfer/discharge to the DHHS Hearing Office WITHIN 11 CALENDAR DAYS of the
date of this notice if you want to continue to stay at this facility. The appeal will be at no cost to you or your representative. The
th
request for an appeal (see attached form) must be received by the hearing officer no later than the 11
calendar day or your right to
appeal is waived. If you wish to review your medical record, we must allow you to see it no later than five working days prior to the
hearing.
You may wish to contact your regional LONG TERM CARE OMBUDSMAN for help in mediation with the facility or for
assistance in obtaining free legal services, if qualified. The ombudsman’s name, address and phone number is:
7)
NAME:____________________________________________________________________________________
ADDRESS: ______________________________________________ PHONE: ________________________
If mentally ill or developmentally disabled, you or your family member or legal representative may wish to contact:
DISABILITY RIGHTS NORTH CAROLINA, 3724 National Drive, Suite 100, Raleigh, NC 27612. Telephone number:
(919) 856-2195 or 1-877-235-4210 or TTY 1-888-268-5535
8)
_______________________________________________
________________________________
Signature of Administrator
Date
DMA-9050 (5/2015)
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