Nursing facility notification form

1. Nursing Facility Notification Form

• Nursing Facility Notification Form

nursingfacility@amerigroup.com

New form submission received: Nursing Facility Notification Form

Facility information

* Facility tax ID #

* Facility NPI #

Facility name

Facility city

Name (Facility point of contact)

Facility contact phone #

Service coordinator name

Resident Information

* Resident / member Medicaid ID #

* Resident / member name

Select reason for Nursing Facility form submission

New admission, Wellpoint member

Date of admission

Discharge - extended leave from facility

Date of discharge

Discharge to hospital / emergency room

Date of discharge

Resident death

Date of death

Re-admission Wellpoint member

Date of re-admission

Significant event or change in condition

Date event / change was identified

Clinical detail - significant event or change in condition detail

Submit