Section He-E 802.19 - Required Forms(a) Each NF informing the department under He-E 802.02(b) shall complete and submit Form 3820, "Change of Status/Transfer/Discharge Form" (September 2020).(b) Each NF notifying the department under He-E 802.07(b)(3), (d) (3), and (e)(2)c. shall complete and submit Form 277, "Utilization Review Form" (September 2020).(c) Each NF notifying the department under He-E 802.07(d)(3)c. shall complete and submit Form 3825, "Memory and Behavior Checklist" (September 2020).(d) Each NF notifying the department under He-E 802.07(d)(3)d. shall submit a behavior summary which includes the same information as the bureau's Form 3830, "Behavior Summary Report" (September 2020).(e) Each NF requesting a specialized rate setting shall complete and submit Form "Specialized Service Rate Request Form-Nursing Facility" (September 2020) to the department.N.H. Admin. Code § He-E 802.19
Derived from Volume XL Number 46, Filed November 12, 2020, Proposed by #13130, Effective 10/30/2020, Expires 10/29/2030 (formerly He-E 802.18).