Nursing Home Transfer and Discharge Notice Attachment



1625608572500 LONG-TERM CARE OMBUDSMAN PROGRAM REQUEST FOR REVIEW OF NURSING HOME DISCHARGE OR TRANSFER Nursing Home Transfer and Discharge Notice Attachment Complete this form if the resident wishes to request the assistance of or review by the Local Long-Term Care Ombudsman Program regarding a nursing home transfer or discharge. All information must be completed. Please print. NURSING HOME INFORMATION NAME OF NURSING HOME: _____________________________________________________________ADDRESS: ____________________________________________________________________________CITY: ________________________________ STATE: ________________ ZIP: ____________________AREA CODE/PHONE #: (____) ____________________________FAX: ______________________RESIDENT INFORMATIONResident name: _____________________________________________________________________RESIDENT’S REPRESENTATIVE: ________________________________________________________REPRESENTATIVE’S RELATIONSHIP TO RESIDENT: ______________________________________REPRESENTATIVE’S ADDRESS: _________________________________________________________CITY: ________________________________ STATE: ________________ ZIP: ____________________AREA CODE/PHONE #: (____) ____________________________________________________________I disagree with the transfer or discharge for the following reason (Use additional sheet if necessary): _____________________________________________________________________________________________________________________________________________________________________________ Check if this involves an emergency discharge or transfer._________________________________________________________________________Resident or Representative Signature Printed NameDatePlease send completed form to the Local Long-Term Care Ombudsman Program, see list of offices on the back of this form. You may also call the Ombudsman Toll-Free at (888) 831-0404.LONG-TERM CARE OMBUDSMAN PROGRAM DISTRICT OFFICE 1-888-831-0404 NORTHWEST FLORIDA 1101 Gulf Breeze ParkwayBuilding 3, Suite 5Gulf Breeze, FL 32561850-916-6720Fax: 850-916-6722Serving: Escambia, Santa Rosa, Okaloosa, & Walton PANHANDLE 4040 Esplanade WayTallahassee, Florida 32399850-921-4703Fax: 850-921-4804Serving: Holmes, Jackson, Washington, Bay, Calhoun, Gadsden, Liberty, Gulf, Franklin, Leon, Madison, Taylor, Jefferson, & Wakulla NORTH CENTRAL FLORIDA - 1515 E Silver Springs Boulevard, #203Ocala, FL 34470352-620-3088Fax: 352-732-1797Serving: Hamilton, Suwannee, Columbia, Lafayette, Dixie, Levy, Union, Putnam, Alachua, Bradford, & Gilchrist, Marion, Citrus, Hernando, Sumter & LakeFIRST COAST Midtown Center Office Center Park, #33004161 Carmichael Avenue, Suite 141Jacksonville, FL 32207904-391-3942Fax: 904-391-3944Serving: Nassau, Baker, Duval, Clay, St. Johns, Volusia & Flagler WEST COAST11351 Ulmerton Road, Suite 303Largo, FL 33778727-501-5515Fax: 727-588-3648Pasco and Pinellas countiesWEST CENTRAL FLORIDA 701 W Fletcher Avenue, Suite CTampa, FL 33612813-558-5591Fax: 813-375-3932Serving: Hillsborough and Manatee EAST CENTRAL FLORIDA 988 Woodcock Road, Suite 198Orlando, FL 32803407-580-6459Fax: 407-245-0653Serving: Orange, Seminole, Brevard, & Osceola SOUTHWEST FLORIDA 2295 Victoria Ave. Room 152Ft. Myers, FL 33901239-338-2563Fax: 239-338-2549Serving: Sarasota, Desoto, Charlotte, Glades, Lee, Hendry, & Collier –PALM BEACH COUNTY111 S. Sapodilla Avenue #125A-B-CWest Palm Beach, FL 33401561-837-5038Fax: 561-650-6885Serving: Palm Beach County BROWARD COUNTY 8333 W. McNabb Road, Suite 231Tamarac, FL 33321954-597-2266Fax: 954-597-2268Serving: Broward NORTH DADE - 13 7270 NW 12th Street, Suite 520Miami, FL 33126786-336-1418Fax: 786-336-1424Serving: N. Miami-Dade – (North of Flagler St., All of Hialeah & N.E. and N.W. addresses)SOUTH DADE & THE FL KEYS7300 N. Kendall Drive, Suite 780Miami, FL 33156305-671-7245Fax: 305-671-7247Serving: Monroe & S. Miami-Dade – (South of Flagler St., all S.E. & S.W. addresses)SOUTH CENTRAL FLORIDA 200 N Kentucky Avenue, #224Lakeland, FL 33801863-413-2764Fax: 863-413-2766Serving: Polk, Highland Hardee, Martin, St. Lucie, Indian River & Okeechobee ................
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