Fill in a Valid New Hampshire 3820 Form

Fill in a Valid New Hampshire 3820 Form

The New Hampshire 3820 form is a crucial document utilized by the Bureau of Elderly & Adult Services to manage changes in the status of residents within long-term care nursing facilities. This form facilitates the transfer, discharge, or change of status for individuals receiving Medicaid benefits, ensuring that all necessary information is communicated effectively between facilities. Understanding how to properly fill out this form is essential for a smooth transition; start the process by clicking the button below.

Edit New Hampshire 3820 Online

The New Hampshire 3820 form serves a critical role in the management of long-term care for residents within nursing facilities. Specifically designed for use by the Bureau of Elderly & Adult Services, this form facilitates the process of notifying relevant parties about changes in a resident's status, including transfers, discharges, or other significant updates. It is primarily utilized for clients who are currently enrolled in the Intermediate Care Facility (ICF) Medicaid program. Key information captured on the form includes the resident's name, Medicaid ID number, and details regarding their current facility, along with the necessary contact information. The form also addresses various scenarios such as the start and stop dates for Medicare, the anticipated or actual discharge date, and the community address to which the resident may be transitioning. Additionally, it requires signatures from both the facility representative and a Bureau representative, ensuring that all changes are documented and verified. With its comprehensive nature, the New Hampshire 3820 form plays an essential part in ensuring a smooth transition for residents while maintaining compliance with state regulations.

Example - New Hampshire 3820 Form

 

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 NotificationTo 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

Discover More on This Form

What is the New Hampshire 3820 form?

The New Hampshire 3820 form is a document used by the Bureau of Elderly & Adult Services to manage changes in status for residents in long-term care nursing facilities. It is specifically designed for current ICF Medicaid clients and is utilized for transfers, discharges, or changes in the resident's status. This form ensures that the necessary notifications and updates are communicated effectively between facilities and relevant parties.

Who should fill out the New Hampshire 3820 form?

The form should be completed by facility representatives or authorized personnel involved in the care of the resident. This includes nursing facility staff who are managing the resident's transition, whether it be a transfer to another facility, discharge to the community, or any change in Medicaid status.

What information is required on the form?

The form requires several key pieces of information. This includes the resident's name, Medicaid ID number, details about the current and new facility, and the dates of any changes in status. Additionally, the form asks for signatures from both the facility representative and a Bureau of Elderly & Adult Services representative to validate the changes being reported.

How is the New Hampshire 3820 form submitted?

The completed form must be faxed to the Bureau of Elderly & Adult Services at (603) 271-7985. It is important to ensure that all information is accurate and complete before submission to avoid delays in processing the resident's status change.

What happens after the form is submitted?

Once the form is submitted, the Bureau will process the changes and send a new Notice of Medical Eligibility to the new facility if the resident is being transferred. This ensures that the new facility has the necessary information to continue providing appropriate care and services to the resident.

Is there a deadline for submitting the New Hampshire 3820 form?

While there is no specific deadline stated, it is crucial to submit the form as soon as a change in status is known. Timely submission helps avoid complications with the resident’s care and ensures that Medicaid services remain uninterrupted.

Can the form be used for both transfers and discharges?

Yes, the New Hampshire 3820 form can be used for both transfers to another nursing facility and discharges to the community. It provides a structured way to communicate any changes in the resident's status, ensuring that all necessary parties are informed and that proper procedures are followed.

What should I do if I need assistance filling out the form?

If assistance is needed, it is advisable to contact the Bureau of Elderly & Adult Services directly. They can provide guidance on how to complete the form accurately and answer any specific questions related to the process. Ensuring that the form is filled out correctly is vital for the resident's continued care.

Misconceptions

  • Misconception 1: The New Hampshire 3820 form is only for discharges.
  • This form is also used for transfers between facilities and changes in status, not just discharges.

  • Misconception 2: You can submit the form without any supporting documentation.
  • It's important to include all necessary information and documentation to ensure a smooth process.

  • Misconception 3: The form is only applicable to Medicaid clients.
  • While primarily for Medicaid clients, it can also be used for Medicare-related changes.

  • Misconception 4: You must fill out the form in person.
  • The form can be faxed to the appropriate office, making it easier to submit remotely.

  • Misconception 5: The form must be submitted immediately upon change.
  • There is a timeline for submission, but it may vary based on the specific situation.

  • Misconception 6: All nursing facilities in New Hampshire accept the 3820 form.
  • Not all facilities may recognize or accept this form, so it's wise to check with the specific facility first.

  • Misconception 7: The form is only for residents who are elderly.
  • This form applies to all adult residents in long-term care, not just the elderly.

  • Misconception 8: Once submitted, you cannot make changes to the form.
  • If mistakes are found after submission, it is possible to correct them with the proper procedures.

  • Misconception 9: The form is not necessary if the resident is being transferred to a different state.
  • Even for out-of-state transfers, this form may still be required for record-keeping and Medicaid purposes.

  • Misconception 10: You don’t need a representative's signature on the form.
  • Both the facility representative and a BEAS representative must sign the form for it to be valid.

Similar forms

  • New Hampshire 3820 Form: This form is specifically used for notifying changes in the status of residents in nursing facilities. It addresses transfers, discharges, and changes in Medicaid status, ensuring that all relevant parties are informed and that proper documentation is maintained.

  • Florida Horse Bill of Sale Form: Essential for anyone buying or selling horses, the detailed Horse Bill of Sale documentation ensures that the ownership transfer is legally recognized and protects the interests of both parties.

  • Medicaid Application Form: Like the 3820 form, the Medicaid application form collects essential information about the applicant's financial and medical status. Both documents are crucial for determining eligibility and ensuring that individuals receive the necessary care and services.

  • Nursing Facility Admission Agreement: This agreement outlines the terms of residency in a nursing facility. Similar to the 3820 form, it requires detailed information about the resident and ensures that both the facility and the resident understand their rights and responsibilities.

  • Discharge Planning Form: This form is used to plan for a resident's discharge from a nursing facility. It shares similarities with the 3820 form in that it documents the anticipated discharge date and the next steps for the resident, whether that be a transfer or returning to the community.