New Hampshire Form 3820 PDF Details

Life's transitions often require a careful blend of communication and official documentation, especially when it comes to changes in the living situations of our elderly and adult family members who are in long-term care facilities. This is where the New Hampshire 3820 form plays a crucial role. Specifically designed by the Bureau of Elderly & Adult Services, this form serves as a vital communication tool for long-term care nursing facilities in New Hampshire. It is used to report any change of status, transfer, or discharge of a resident who is a current Intermediate Care Facility (ICF) Medicaid client. The form captures a wide range of essential details, including the resident's name, Medicaid ID number, facility contact information, and the specific status change, whether it's a transfer between facilities, discharge to the community under the Community for Independence (CFI) program, or even more sensitive information like a resident's passing. Additionally, it includes Medicare start and stop dates among other crucial dates that ensure continuity of care and proper Medicaid billing. Through this form, facilities can notify the appropriate state authorities, by fax, of any significant changes, facilitating a seamless transition for the resident and maintaining compliance with Medicaid regulations. Such a document underscores the importance of meticulous record-keeping in the healthcare sector, particularly in the context of long-term care, ensuring that every step in a resident's care journey is documented and communicated effectively.

QuestionAnswer
Form NameNew Hampshire Form 3820
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesForm3820NFChang eofStatusPDFJan 2011 nursing facility change of statustransferdischarge form

Form Preview Example

 

Bureau of Elderly & Adult Services

 

 

Long Term Care

 

Nursing Facility Change of Status/Transfer/Discharge Form

 

FAX TO:

(603) 271-7985

 

 

 

 

Resident Name: Last:

First:

MI:

Medicaid ID Number:

Facility:

 

Phone Number:

Fax Number:

 

 

 

 

 

Status of Change Notification – To be used only for current ICF Medicaid clients

Medicare Start Date:

 

Medicare Stop Date:

 

 

 

 

Resume Medicaid status date:

Date of Death:

Transfer from one New Hampshire nursing facility and/ or CFI to nursing facility

(New Notice of Medical Eligibility will be sent to new facility) Name of nursing facility, or for CFI, date being transferred from:

Name of facility being transferred to:

Fax:Phone:

Date of transfer:

Change of date request: Original Medicaid start date approved: Actual Medicaid start date:

Original discharge date from facility:

Actual discharge date from facility:

Discharge to Community (CFI program) –

Date entered Nursing Facility:

Anticipated or Actual Date Of Discharge to Community:

Community address:

Phone number (if known):

Facility Representative Signature

Date:

BEAS Representative Signature

 

Date:

 

 

 

Form #3820. Revised 1/2011

How to Edit New Hampshire Form 3820 Online for Free

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This form will require particular details to be filled out, thus make sure you take some time to fill in what's asked:

1. When completing the New Hampshire Form 3820, make certain to include all necessary fields in their associated area. It will help to speed up the work, enabling your information to be handled swiftly and properly.

Stage no. 1 of filling in New Hampshire Form 3820

2. Once your current task is complete, take the next step – fill out all of these fields - Change of date request, Original Medicaid start date, Actual Medicaid start date, Original discharge date from, Actual discharge date from facility, Discharge to Community CFI program, Date entered Nursing Facility, Anticipated or Actual Date Of, Community address, Phone number if known, Facility Representative Signature, BEAS Representative Signature, Form Revised, Date, and Date with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

New Hampshire Form 3820 completion process outlined (part 2)

Always be extremely attentive while filling out Actual discharge date from facility and Discharge to Community CFI program, as this is the section in which many people make errors.

Step 3: You should make sure the information is correct and then press "Done" to progress further. Right after getting a7-day free trial account here, it will be possible to download New Hampshire Form 3820 or send it via email promptly. The file will also be readily available through your personal account menu with your each modification. FormsPal ensures your data privacy by using a protected method that never records or distributes any kind of personal data involved. You can relax knowing your paperwork are kept safe every time you use our service!

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