Free NOTICE OF TRANSFER OR DISCHARGE AND BED HOLD - Indiana

NOTICE OF TRANSFER OR DISCHARGE
State Form 49669 (R4 / 11-06)

Indiana State Department of Health-Division of Long Term Care

Resident Name Facility Name (Facility resident is being discharged from) Facility Street Address (number and street) Transfer or Discharge Effective Date (month, day, year) Resident is being transferred to:
Another Nursing Facility (Please Specify Facility Name): Another Health Facility (Please Specify Facility Name): A private residence (including home) Other (Please specify)

Date Issued (month, day, year)

Facility City

Facility ZIP Code

Transfer or Discharge to Address (number and street)

Transfer/Discharge to City, State, ZIP Code

Reason for Transfer or Discharge (must select one of the reasons below)
The transfer or discharge is necessary to meet the resident's welfare and the resident's needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the nursing facility. The safety of the individuals in the facility is endangered. The health of the individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or payment has not been made under Medicare/Medicaid for a stay in a nursing facility. The facility ceases to operate.

APPEAL RIGHTS You have the right to appeal the health facility's decision to transfer you. If you think you should not have to leave this facility, you may file a written request for a hearing with the Indiana State Department of Health postmarked within ten (10) days after you receive this notice. If you request a hearing, it will be held within twenty-three (23) days after you receive this notice, and you will not be transferred from the facility earlier than thirty-four (34) days after you receive this notice of transfer or discharge, unless the facility is authorized to transfer you as an emergency transfer under 410 IAC 16.2-3.1-12(a)8. If you wish to appeal this transfer or discharge, please fill out the attached State Form 49831 and return to the address below. If you have any questions, call the Indiana State Department of Health at 317-233-7794 between the hours of 8:15 am and 4:45 pm. To appeal this transfer or discharge, use the attached State Form 49831 and mail it to: Indiana State Department of Health Division of Long Term Care 2 North Meridian St. Section 4-B Indianapolis, IN 46204

A facility must permit each resident to remain in the facility and may not transfer or discharge the resident unless: The transfer or discharge is necessary to meet the resident's welfare and the resident's needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the nursing facility.. The safety of the individuals in the facility is endangered. The health of the individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay or payment has not been made under Medicare/Medicaid for a stay in a nursing facility. The facility ceases to operate. A resident also has the following rights regarding a discharge: The right to discuss with the administrator the facility's decision. Reasonable assistance from the nursing home in carrying out the transfer/discharge plan, including helping resident contact other facilities and transferring your records when you leave. A discharge planning conference with the nursing home. The Ombudsman is a State Office that serves as an advocate for nursing home residents. The State long term care Ombudsman's address and telephone number is: State Ombudsman Family and Social Services Administration Division of Disability, Aging and Rehabilitative Services Bureau of Aging and In-Home Services P.O. Box 7083, 402 W. Washington St. IGC South, Room. W454 Indianapolis, IN 46207-7083 317/232-7134 or Toll free 1-800-622-4484 Your Local Ombudsman: Name Address(number and street, city, state and ZIP code) The Protection and Advocacy organization provides assistance if needed for residents who are mentally ill or developmentally disabled. Their address and telephone number is: Indiana Protection and Advocacy Services 4701 North Keystone Avenue, Suite 222 Indianapolis, IN 46205 Voice 1-800/622-4845 or 317/722-5555 TTY 1-800/838-1131; Fax 317/722-5564 Telephone number