New Hampshire Form 3820 PDF Details

Do you need to file New Hampshire Form 3820? It can be a confusing task, especially if you're unfamiliar with the process. But we have good news: understanding and completing your Form 3820 correctly is easier than it looks! In this blog post, we'll cover what the form is and how to complete it properly so that you can ensure compliance with New Hampshire law. Read on for an overview of everything you need to know about filing your Form 3820.

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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