Fillable Printable Form 49669
Fillable Printable Form 49669
Form 49669
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NOTICE OF TRANSFER OR DISCHARGE
State Form 49669 (R7 / 5-17)
Indiana State Department of Health - Division of Long Term Care
Resident Information
Resident Name
Date Notice Issued (month, day, year)
Facility Name (Facility resident is being discharged from)
Facility Street Address (number and street)
Facility City
Facility ZIP Code
Transfer / Discharge Notice
Transfer or Discharge Effective Date (month, day, year)
Resident Is Being Transferred To:
Another Nursing Facility (Specify facility name below.)
Another Health Facility (Specify facility name below.)
A private residence (including home)
Other (Please specify):
Name of Facility Being Transferred To
Address of Facility Being Transferred To (number and street)
City
State
ZIP Code
Reason for Transfer or Discharge (Must select one of the reasons below.)
The transfer or discharge is necessary to meet the resident’s welfare and the resident’s needs
cannot be met in the facility.
The transfer or discharge is appropriate because the resident’s health has improved
sufficiently so the resident no longer needs the services provided by the nursing facility.
The safety of the individuals in the facility is endangered.
The health of the individuals in the facility would otherwise be endangered.
The resident has failed, after reasonable and appropriate notice, to pay or payment has not
been made under Medicare/Medicaid for a stay in a nursing facility.
The facility ceases to operate.
Bed Hold Policy
The facility must attach a copy of the facility’s bed hold policy to this Notice of Transfer or Discharge and provide
contact information for a facility employee to contact about the bed hold policy.
Facility Contact Name
Facility Contact Title
Facility Contact Telephone Number
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Appeal Rights
You have the right to appeal the health facility’s decision to transfer you. If you think you
should not have to leave this facility, you may file a written request for a hearing with the
Indiana State Department of Health postmarked within ten (10) days after you receive this
notice. If you request a hearing, it will be held within twenty-three (23) days after you receive
this notice, and you will not be transferred from the facility earlier than thirty-four (34) days
after you receive this notice of transfer or discharge, unless the facility is authorized to transfer
you as an emergency transfer under 410 IAC 16.2-3.1-12(a)8. If you wish to appeal this
transfer or discharge, please fill out the attached State Form 49831 and return to the address
below. If you have any questions, call the Indiana State Department of Health at 317-233-7540
between the hours of 8:15 am and 4:45 pm.
To appeal this transfer or discharge, use the attached State Form 49831 and mail it to:
Indiana State Department of Health
Court Administrator, Office of Legal Affairs
2 North Meridian St. Section 3-H
Indianapolis, IN 46204
Attachments
The facility must attach the following documents to this Notice of Transfer or Discharge:
Attach facility bed hold policy
Attach State Form 49831 Notice of Transfer or Discharge Request for Hearing
State Long Term Care Ombudsman
The State Ombudsman is a State Office that serves as an advocate for nursing home residents.
The State long term care Ombudsman’s address and telephone number is:
State Ombudsman
Family and Social Services Administration
P.O. Box 7083, 402 W. Washington St.
IGC South, Room W451 – MS 27
Indianapolis, IN 46207-7083
317/232-7134 or Toll free 1-800-622-4484
http://www.in.gov/fssa/da/3474.htm
Your Local Ombudsman
The following is contact information for your local Ombudsman:
Name of Local Ombudsman
Telephone of Local Ombudsman
Address of Local Ombudsman (number and street)
City
State
ZIP Code
Indiana Disability Rights
The Indiana Disability Rights organization provides assistance, if needed, for residents who are mentally ill or
developmentally disabled. Their address and telephone number is:
Indiana Disability Rights
4701 North Keystone Avenue, Suite 222
Indianapolis, IN 46205
Voice 1-800/622-4845 or 317/722-5555
TTY 1-800/838-1131; Fax 317/722-5564
http://www.IndianaDisabilityRights.org
