LONG TERM CARE ADMISSION AND DISCHARGE TRANSMITTAL 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the RESIDENT DATA section. Enter the resident's name, access number, social security number, birthdate, sex, and county. Ensure all fields are filled accurately to avoid delays.
3. In the PROVIDER DATA section, input the facility name, service provider ID, attending physician's name and their identification number. This information is crucial for proper documentation.
4. Move to DISCHARGE PLANNING DATA. Record the date of the current discharge plan and confirm if it includes necessary items (a-f). If any items are marked 'No', provide explanations in the comments section.
5. For CHANGE OF CARE RECOMMENDATIONS, indicate if a change in care is needed by checking the appropriate box and summarizing the resident’s condition.
6. Complete the TRANSFER/DISCHARGE SECTION by marking discharge codes and indicating whether a 30-day notice was sent. Record relevant dates as required.
7. Finally, ensure that an administrator or designee signs and dates the form to validate its accuracy before submission.

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