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

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

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

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