New Hampshire Form 3820 at a glance
What it is: BAAS 3820, Change Of Nursing Facility Status (Transfer or Discharge), is a form of the NH Department of Health and Human Services (DHHS), Bureau of Adult & Aging Services (BAAS).
Where and when to file: Upload completed forms to www.NHEASY.nh.gov or fax a copy to BAAS, Attn: LTC Medical Eligibility Unit at 603-271-7985.
A filled-in New Hampshire Form 3820 example: a resident transferred to another nursing facility
How to fill out New Hampshire Form 3820, box by box
Change of Status Type
Under Change of Status Type, mark Change of Status Involving Transfer Between Nursing Facility or Waiver Services (NF to CFI) OR Other Change of Status and Specify it.
Resident and Facility Information
Under Resident and Facility Information, enter the Medicaid ID Number, the Date of Death (If applicable), and the First Name, Middle and Last name.
Enter the Facility Name, Phone Number and Fax Number.
Status of Change Notification
Under Status of Change Notification (For individuals who stay is paid by Medicare), enter the Medicare Start Date and Medicare End Date.
Enter the Initial LTC Effective Date, the Resume Medicaid Status Date and the Level of Care Requested (ICF, SNF, Atypical, or Swing).
Facility to Facility Transfer
Under Facility to Facility Transfer, enter the NH Nursing Facility Being Transported From and the NH Nursing Facility Being Transported To.
Enter the Date of Transfer, the Level of Care (ICF, SNF, Atypical, or Swing), the Phone Number (New Facility) and the Fax Number (New Facility).
Change of Date Request
Under Change of Date Request, enter the Original LTC Requested Start Date, the Original Requested Discharge Date and the Revised Discharge Date.
Discharge to Community
Under Discharge to Community, enter the Date Entered Facility and the Date Discharged to Community, and check the appropriate box to indicate which program(s) or service(s) the recipient Will be receiving in the community.
The boxes are CFI Program, Skilled Home Care, Transitional Case Management (Placement in Facility for at least 30 days AND is open NH Medicaid) and Other Waiver Program (Specify).
Enter the Resident's Discharge Address and the Resident's Phone Number Upon Discharge.
Admission to Nursing Facility While Receiving Waiver Services
Under Admission to Nursing Facility While Receiving Waiver Services, enter the Name of Admitting Facility, the Date of Admission, the Facility Address and the Level of Care (ICF, SNF, Atypical, or Swing).
Enter the Facility Phone Number and Facility Fax Number, and check the appropriate box to indicate which program(s) or service(s) the recipient WAS receiving prior to admission to the Nursing Facility: CFI Program or Other Waiver Programs (Specify) (Requires valid MEA, MDS, or OASIS).
Please also submit the individual's medical history. This form replaces the need to submit a new application.
The individuals history and physical, therapy notes, transition plan, plan of care and nursing assessments are still required.
Signature
Under Signature, the Facility Representative enters the Printed Name, Title, Signature and Date.
Common questions about New Hampshire Form 3820
Where do I file it?
Upload completed forms to www.NHEASY.nh.gov or fax a copy to BAAS, Attn: LTC Medical Eligibility Unit at 603-271-7985.
Sources
[1] BAAS 3820 (Rev 11/25), Change Of Nursing Facility Status (Transfer or Discharge), NH Department of Health and Human Services (the Official source link on this page).