Long-Term Care Ombudsman Council Request For Review Of Nursing Home Discharge Or Transfer

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LONG-TERM CARE OMBUDSMAN COUNCIL
REQUEST FOR REVIEW OF NURSING HOME DISCHARGE OR TRANSFER
Nursing Home Transfer and Discharge Notice Attachment
Complete this form if the resident wishes to request the assistance of or review by the Local Long-Term Care
Ombudsman Council regarding a nursing home transfer or discharge. All information must be completed.
Please print.
NURSING HOME INFORMATION
NAME OF NURSING HOME: _____________________________________________________________
ADDRESS: ____________________________________________________________________________
CITY: ________________________________ STATE: ________________ ZIP: ____________________
AREA CODE/PHONE #: (____) ____________________________
FAX: ______________________
RESIDENT INFORMATION
RESIDENT NAME: _____________________________________________________________________
RESIDENT’S REPRESENTATIVE: ________________________________________________________
REPRESENTATIVE’S RELATIONSHIP TO RESIDENT: ______________________________________
REPRESENTATIVE’S ADDRESS: _________________________________________________________
CITY: ________________________________ STATE: ________________ ZIP: ____________________
AREA CODE/PHONE #: (____) ____________________________________________________________
I disagree with the transfer or discharge for the following reason (Use additional sheet if necessary):
_______________________________________________________________________________________
_______________________________________________________________________________________
Check if this involves an emergency discharge or transfer.
__________________________________
___________________________
____________
Resident or Representative Signature
Printed Name
Date
Please send completed form to the Local Long-Term Care Ombudsman Council, see list of offices on
the back of this form. You may also call the Ombudsman Toll-Free at (888) 831-0404.
AHCA Form 3120-0004 Nov. 2010
AHCA LTC, 2727 Mahan Dr, MS 33, Tallahassee, FL 32308 (850) 412-4303

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