Skilled Nursing Facility 3-Day Hospital Stay Waiver Form

Skilled Nursing Facility 3-Day Hospital Stay Waiver Form
Complete this form to request review of a waiver related to the 3-day hospital stay requirement for skilled nursing facility admission.
Patient and Resident Information
Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Hospital Stay and Eligibility Details
Hospital Name
Admission Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Hospital Stay Length (Days)
Stay Was at Least 3 Consecutive Days
Primary Reason for Hospitalization or Diagnosis Summary
Skilled Nursing Facility Admission Details
Skilled Nursing Facility Name
Facility Location or Branch
Planned Admission Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Admissions Contact Person or Department
Responsible Party and Insurance Information
Responsible Party Name
First NameLast Name
Relationship to Patient/Resident
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Insurance Provider or Plan Name
Waiver Acknowledgement and Signature
Signature of Patient or Authorized Representative
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Date of Signature
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Skilled Nursing Facility 3-Day Hospital Stay Waiver Form

Patient and Resident Information

Hospital Stay and Eligibility Details

Skilled Nursing Facility Admission Details

Responsible Party and Insurance Information

Waiver Acknowledgement and Signature