12934 Nursing Home Ombudsman Poster - The Agency For Health 2026

1. Click ‘Get Form’ to open the Nursing Home Ombudsman Poster in our editor.
2. Begin by entering the Resident Information. Fill in the resident's name and Medicaid ID number if applicable, along with their address.
3. Next, provide the Nursing Home Information. Include the facility's name and contact details, ensuring accuracy for effective communication.
4. If applicable, fill out the Resident Representative section with their name and contact information to ensure they are informed about the transfer or discharge.
5. Indicate the date notice is given and specify the location to which the resident is being transferred or discharged. Remember that this effective date must be at least 30 days from when notice is given unless exceptions apply.
6. Select a reason for discharge or transfer from the provided options. If necessary, attach additional documentation to support your choice.
7. Finally, ensure all signatures are completed where required, including those of nursing home administrators and physicians if applicable.

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