Free NOTICE OF TRANSFER OR DISCHARGE REQUEST FOR HEARING - Indiana

NOTICE OF TRANSFER OR DISCHARGE REQUEST FOR HEARING
State Form 49831(R4/12-06) Indiana State Department of Health-Division of Long Term Care

Use this form to notify the Indiana State Department of Health that you wish to appeal your transfer/discharge. If you want to appeal the transfer or discharge, you must send it to the Department of Health within 10 days of your receiving the notice of transfer or discharge from the facility to: Director, Transfer/Discharge Program Indiana State Department of Health 2 North Meridian Street ­ Section 4-B Indianapolis, Indiana 46204 I hereby request a hearing on the decision to transfer or discharge me from a nursing facility. Resident Name Date (Month, Day, Year) Resident's Representative Name Representative Address (Number and Street) Representative Telephone Number

Facility Name (Facility resident is being discharged from) Facility Street Address (Number and Street) Facility City Facility ZIP Code

Facility Telephone Number (

)

Reason for Transfer or Discharge (as listed on the "Notice of Transfer or Charge" form)
The transfer 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.

Nursing Facility Bed Hold Policy
The bed-hold policy under the Family and Social Services Administration, Office of Medicaid Policy and Planning (405 IAC 5-31-8): Reservation of nursing facility beds. Although it is not mandatory for facilities to reserve beds, Medicaid will reimburse for reserved beds for Medicaid recipients at one-half the per diem rate provide that the criteria set out in 405 IAC 5-31-8 is met. Hospitalization: Hospitalization must be ordered by the physician for treatment of an acute condition that cannot be treated in the nursing facility The total length of time allowed for payment of a reserved bed for a single hospital stay is 15 days Therapeutic leaves of absence: A leave of absence must be for therapeutic reasons, as prescribed by the attending physician and as indicated in the recipient's plan of care The total length of time allotted for therapeutic leave in any calendar year is 30 days. The leave days need not be consecutive Medicaid will not reimburse a nursing facility for reserving beds for Medicaid recipients when the nursing facility has an occupancy rate of less than ninety (90) percent. Although prior authorization by the office is not required to reserve a bed, a physician's order for the hospitalization or therapeutic leave must be on file in the nursing facility. Facility bed hold policy:

Facility Bed Hold Policy Contact: