Sample Discharge Letter [OALA Member Letterhead] [Date] Note: It is assumed that you are hand delivering this to the resident on the day that it is dated. If mailed to the resident, the 30 days is effective from the date of their receipt of it. [Resident Name & Address] Dear Mr./Mrs. [Resident name]: We regret to inform you that due to the circumstances noted below you will be discharged from our facility effective thirty days after the date of this notice, on __________________. The name (if applicable) and address of the proposed location to which you will be discharged to is ______________________________________________________. We will assist you in arranging for the discharge. If you have another location to which you would like to be discharged, or if you would like assistance with locating an alternate location to which to be discharged, please let us know. The reason(s) for this discharge is/are that [choose the reasons that apply and delete those that do not apply] • you have failed, after reasonable and appropriate notice to pay, or to have the Medicare or Medicaid program pay on your behalf, for the care provided by our facility; • your welfare and needs cannot be met in our facility; • the safety of individuals in our facility is endangered; • the health of individuals in our facility would otherwise be endangered; • your health has improved sufficiently so that you no longer need the services of the facility. You may request an impartial hearing to be conducted by the Department of Health at our facility regarding this notice and the proposed discharge. If a hearing is desired, such hearing must be requested no later than thirty days after you receive this notice, by submitting a written request to the Legal Services Office of the Department of Health, which is located at 246 North High Street, Columbus, Ohio 43215, and at the following phone number: (614) 466-4882. If you wish to request a hearing, then you should enclose a copy of this notice with the hearing request. Additionally, a copy of the hearing request should be sent to [AL Manager Title] of our facility. A hearing will be held at our facility within ten days of receipt of the request by the Department of Health. 216.514.1100 [email protected] Note that we will not discharge you before the date indicated in the first paragraph of this letter, unless we reach agreement with you or your representative/sponsor to do so on an earlier date. [The following sentence must be in bold type] Note also that if you request a hearing no later than ten days after you receive this notice, then we will not discharge the resident unless we prevail at the hearing. If you request a hearing more than ten days after you receive this notice, then the resident will be discharged on the date noted above. However, if you request a hearing after ten days of receiving this notice, but within thirty days of receiving it, then a hearing will be scheduled, and if you prevail in the hearing, then we will readmit the resident to the first available bed. If you need assistance in requesting a hearing, the Ombudsman for this facility is named ___________________________, and he/she can be contacted at the following address _________________________________________________________________, or phone number: _________________. The Ohio State Long-Term Care Ombudsman is Beverly Laubert, 50 W. Broad St, 9th Floor, Columbus, OH 43215, (800) 282-1206. In addition, if you have a developmental disability or mental illness, then you may wish to seek the assistance of the Ohio Legal Rights Service, which can be contacted at 50 West Broad Street, Suite 1400, Columbus, Ohio 43215, (614) 466-7264. If you have any questions about this notice, please contact me at the following phone number: ____________________. Sincerely, [AL Manager Name & Title] Copy to: Ohio Department of Health, Legal Services Office 246 North High Street, Columbus, Ohio 43215 (614) 466-4882 [Resident’s Sponsor/Representative] [Note that the representative’s copy of the notice must be sent via certified mail, return receipt requested.] Rolf/AM 2010