1. Adaptive Form Title
2. Main Panel
3. Thank You

• Main Panel
  • FACILITY INFORMATION
  • RESIDENT'S INFORMATION
  • NOTIFICATION AND DATE OF
  • NEW ADMISSION
  • DISCHARGE AND CHANGE
  • SUBMIT
• Thank You

FACILITY NOTIFICATION INFORMATION SHEET

• FACILITY INFORMATION
• RESIDENT'S INFORMATION
• NOTIFICATION AND DATE OF
• NEW ADMISSION
• DISCHARGE AND CHANGE
• SUBMIT

FACILITY INFORMATION

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From (Facility Name):

Facility Contact Person:

Facility Phone:

Facility Address Street:

Facility Address City:

Facility Address State:

Facility Address Zip:

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Is the Mailing Address the Same as the Physical Address Listed Above?

Yes

No

Facility Mailing Street:

Facility Mailing City:

Facility Mailing State:

Facility Mailing Zip:

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Facility Email:

Facility Fax:

Information Type

Application

Change in Circumstances

Verification

RESIDENT'S INFORMATION

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Resident's Name:

Date of Birth:

Spouse's Name:

Date of Marriage:

Social Security Number:

DCN (if known):

NOTIFICATION AND DATE OF: (Please write date of event in appropriate space below.)

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New Admission:

Discharge:

Death:

NEW ADMISSION: (Please complete 1-5 for all admissions, and 6 or 7 if applicable).

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1. Admitted from?

Home

Hospital

Other Facility

2. Date DA-124 sent to COMRU:

3. Date entered a Medicaid-certified bed:

4. Placement (check one):

SNF

ICF

RCF l

ALC/RCF ll

DMH

5. Bed type (check one):

ALF

ICF

MHC

PSY

RC1

SNF

Title 18

Title 19

6. If RCF or ALF monthly base rate for resident:

7. Guardian or Responsible Party and relationship:

ADDRESS: Street

City

State

Zip

Phone

DISCHARGE: (Please complete 1 or 2.)

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1. New facility - facility name and city:

2. Other living arrangement - individual's current address and telephone number:

CHANGE: (Please complete as needed.)

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Describe the Change:

If requesting a review or adjustment to surplus, please explain below:

SUBMIT

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Please attach supporting documents, such as bank statements and pay stubs.

Attach

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Submit

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Thank You

Your request was submitted.

The change request number is {formuniqueid}.

Thank you,

 

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