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
Date
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
Date
Discharge Date
MonthDayYear
Date
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
Date
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
Date
Should be Empty: