Transcription of Transfer Discharge Notice - NORC
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Transfer Discharge Notice - NORC
AHCA Form 3120-0002 Revised May 01 AHCA LTC, 2727 Mahan Dr MS 33, Tallahassee, FL 32308 (850)488-5861 NURSING HOME Transfer AND Discharge Notice Refer to section , Florida Statutes. This form is required for those transfers or discharges initiated by the nursing home facility, and not by the resident or by the resident s physician or legal guardian or representative. Resident Information Name: _____ Medicaid ID # (if applicable): _____ Resident Representative (if applicable) Name: _____ Address: _____ Phone: _____ Nursing Home Information Name: _____ Address: _____ _____ Phone: _____ Facility contact person: _____ Contact phone: _____ Date Notice is given: _____ Effective Date: _____ The effective date must be at least 30 days from date Notice is given unless an exception applies.
AHCA Form 3120-0002 Revised May ’01 AHCA LTC, 2727 Mahan Dr MS 33, Tallahassee, FL 32308 (850)488-5861 NURSING HOME TRANSFER
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