Tenncare Ltss Nursing Facility Notice Of Transfer Or Discharge

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Nursing Facility Notice of
Transfer or Discharge
Refer to 42 CFR 483.12. This form is required for those transfers or discharges initiated
by the nursing facility, and not by the resident, legal guardian or representative.
Resident Information
Name _____________________ Medicaid ID (if applicable) __________________________
Resident Representative (if applicable)
Name _____________________ Address _________________________________________
Phone _____________________
Location to which resident is transferred or discharged (required)
Name _____________________ Address _________________________________________
Phone _____________________
Nursing Facility Information
Name _____________________ Address _________________________________________
Phone __________Facility Contact Name __________________________ Contact Phone ___________
Notice Information
Date notice is given _________________________ Date of Transfer/Discharge____________________
The transfer/discharge date must be at least 30 days after the date the notice is given unless an
exception applies. The resident may choose to move earlier than the effective date.
Reason for discharge or transfer:
Your bill for services at this facility has not been paid after you received notice and time
to pay.
This facility is closing.
For the following reasons, page 2 of this form must be signed by a physician, or a physician’s
written order for discharge or transfer must be attached. The physician may be the resident’s
attending or treating physician, the facility medical director, or a nurse practitioner or
physician’s assistant as a designee to one of the aforementioned.
Your needs cannot be met in this facility.
Your health has improved enough that you no longer need the services provided by this
facility.
The health of other individuals in this facility is endangered.
The safety of other individuals in this facility is endangered.
You must provide a brief explanation to support this action (attach additional documentation if
necessary):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Requesting Assistance
TennCare LTSS dev. 09/2014
TC-0179 (Rev. 06/2016)
RDA 2047

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