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FACILITY NOTIFICATION INFORMATION SHEET

FACILITY INFORMATION

From (Facility Name):

Facility Contact Person:

Facility Phone:

Facility Address Street:

Facility Address City:

Facility Address State:

Facility Address Zip:

RESIDENT'S INFORMATION

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.)

Date Of Admission

Date Of Discharge

Date Of Death

NEW ADMISSION: (Please complete 1-4 for all admissions, and 5 or 6 if applicable).

1. Admitted from?

Home

Hospital

Other Facility

2. Date DA-124 sent to COMRU:

3. Date entered a Medicaid-certified bed:

4. Placement (please check one):

SNF

ICF

RCF l

ALC/RCF ll

DMH

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

6. Guardian or Responsible Party and relationship:

ADDRESS: Street

City

State

Zip

Phone

DISCHARGE: (Please complete 1 or 2.)

1. New facility - facility name and city:

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

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

SUBMIT

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

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