Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62194 (Rev. 07/08)

STATE OF WISCONSIN

TITLE XIX RECIPIENT TERMINATION NOTICE

Completion of this form is voluntary; however, Title XIX reimbursement is determined by the information provided on this form. Residents that are discharged from the nursing home and participate in a COP/CIP program must be terminated by the nursing home before EDS will reimburse for COP/CIP. Terminations for hospitalization should be submitted only when it is known that the resident will not be returning to the facility or when the hospital stay has surpassed the 15-day bed hold. Questions about bed hold should be referred to your Division of Health Care Access and Accountability Auditor. A Title XIX Care Level Determination, F-62256, must be submitted to your Division of Quality Assurance Regional Office prior to submitting a termination notice. Personal information collected on this form will be shared with EDS for reimbursement purposes and will be used for no other purpose. If you have questions about completing this form, contact your DQA Regional Office.
License Number City Telephone Number Reason for Termination See codes below. Date Signed Zip Code

Name - Facility Address SIGNATURE - Person Completing This Form

Resident's Name

Medical Assistance Number

Effective Date of Termination

Date of Admission or Most Recent Readmission

If Code Number 2, indicate name of facility.

TERMINATION CODES
1 ­ Death 2 ­ Transferred to another nursing home or another T19 certified facility 3 ­ Went from private pay to T19 4 ­ Went to a non-institutional living arrangement 5 ­ Loss of appeal 6 - Discharge

Mail this form to your Division of Quality Assurance REGIONAL OFFICE.