Out-of-State Nursing Facility Placement Packet 2026

1. Click ‘Get Form’ to open the Out-of-State Nursing Facility Placement Packet in our editor.
2. Begin with SECTION I: RECIPIENT INFORMATION. Fill in the recipient's name, date of birth, age, and Medicaid ID. If the Medicaid ID is unknown, provide the Social Security number.
3. Complete the guardian information if applicable, including their name, marital status, and contact details. Indicate if guardianship has been applied for.
4. Move to SECTION II: CLINICAL INFORMATION. Answer whether this request is for ICF/IID and attach necessary medical documentation as specified.
5. In SECTION III: SERVICING PROVIDER INFORMATION, enter details about the current provider and case manager. Ensure all contact numbers are accurate.
6. Proceed to SECTION IV: Acknowledgment and Consent. The recipient or guardian must print their name and sign to consent to out-of-state placement.
7. Finally, complete any remaining sections as required before saving your changes and submitting via fax to DHCFP at (775) 687-8724.

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