Tenncare Ltss Nursing Facility Notice Of Transfer Or Discharge Page 2
ADVERTISEMENT
1
2Nursing Facility Notice of
Transfer or Discharge
If you ask, nursing facility staff must give you the help you need to contact one of the people or groups
below. If you disagree with the discharge or transfer, nursing facility staff must give you the help you
need to ask for an appeal. Please see the name and phone number of the nursing home contact person
listed on page 1 of this form.
Long -Term Care Ombudsman
You have the right to ask for a review of this notice by a Long -Term Care Ombudsman. They are
available to help you with any questions about this notice or the appeal process. If you want to ask for
a review of this notice or ask for help from a Long -Term Care Ombudsman, call the Ombudsman Office
toll free at 877-236-0013.You can also ask them for help in writing. Mail your written request to the
State Long-Term Care Ombudsman at 502 Deaderick Street Andrew Jackson Building 9th Floor Nashville,
TN 37243-0860.
TennCare Advocacy Program
Do you have a mental illness and need help with this notice? The TennCare Advocacy Program can help
you. Call them for free at 1-800-758-1638. Do you have an intellectual or developmental disability and
need help with this notice? The Department of Intellectual and Developmental Disabilities can help
you. Call them for free at 1-800-535-9725. You can contact them in writing at 400 Deaderick Street
Citizen’s Plaza State Office Building, Nashville, TN 37243.
Asking for an Appeal of This Decision
You have the right to appeal if you don’t agree with this decision. You have up to 30 days from the date
this notice is given to request a fair hearing. If you ask for a fair hearing within 30 days of the date this
notice is given, you will not be transferred or discharged until the hearing decision has been made,
unless your situation requires an emergency transfer or discharge. If you do not ask for a fair hearing
within 30 days of the date this notice is given, you will be transferred or discharge at the end of the 30-
day notice period.
If you wish to appeal this notice and request a hearing, you must do so in writing. Please attach a copy
of this notice when you send your appeal. Mail your appeal to TennCare’s Office of General Counsel
ATTN: Involuntary NF Discharge Appeals, 310 Great Circle Road, Nashville, TN 37243. You may also
fax your appeal to 615-734-5317. If you have questions about appealing this decision, call TennCare’s
Office of General Counsel for free at 866-797-9469.
Notice presented by:
__________________________________________
_________________________________
______________________
Nursing Home Administrator/Designee Name
Signature
Date
__________________________________________
_________________________________
______________________
Physician/Designee Name (When Required)
Signature
Date
Notice received by:
__________________________________________
_________________________________
______________________
Resident or representative Name
Signature
Date
Notice given to: Resident, Legal Guardian or Rep ____________________ (Date)
Resident Clinical Record __________________ (Date)
Local LTC Ombudsman
_____________________ (Date)
State LTC Ombudsman ____________________ (Date)
HCFA Commissioner’s Designee _____________________ (Date)
TennCare LTSS dev. 09/2014
TC-0179 (Rev. 06/2016)
RDA 2047
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal