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Notice Of Intent To Admit To A Nursing Facility For Short Term Services Form. This is a Massachusetts form and can be use in Probate And Family Court Statewide.
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Tags: Notice Of Intent To Admit To A Nursing Facility For Short Term Services, MPC 829, Massachusetts Statewide, Probate And Family Court
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
NOTICE OF INTENT TO ADMIT
TO A NURSING FACILITY
FOR SHORT TERM SERVICES
Division
In the Interests of:
First Name
Middle Name
Last Name
Incapacitated Person
I. To be completed by the Guardian:
I, the court appointed Guardian, provide this Notice of Intent to Admit the Incapacitated Person to the following nursing facility
as defined by G.L. c. 190B, ยง5-101(15):
Name of Nursing Facility:
Address of Nursing Facility:
(Address)
(City/Town)
(State)
(Zip)
This form SHALL NOT be used if a nursing facility has not been specifically identified.
Expected Date of Admission:
Admission SHALL occur within seven (7) days of filing.
Expected date of discharge:
This form SHALL NOT be used if the expected date of discharge is more than sixty (60) days after the date of admission.
I further state:
1.
I have been involved with the decision to admit and have approved the admission.
2.
This admission is anticipated to be for a period of sixty (60) days or less;
3.
A person authorized to sign a Medical Certificate recommends such admission;
4.
Counsel (you must choose one):
(a)
presently represents the Incapacitated Person:
Name of counsel for the Incapacitated Person:
First Name
(b)
M.I.
Last Name
The Incapacitated Person is not represented by counsel. I understand the Court will appoint counsel for him/her.
5.
A signed copy of this Notice of Intent to Admit to a Nursing Facility has been served in-hand on the Incapacitated
Person; provided to the above-named nursing facility in-hand, by facsimile (fax), or by e-mail; and provided to the
above-named counsel in-hand or by facsimile (fax). See Rule 3 of the Supplemental Rules of the Probate and
Family Court. If counsel is requested herein, a copy of this Notice of Intent to Admit to a Nursing Facility for Short
Term Services will be provided to counsel upon appointment.
6.
The Incapacitated Person does not object and I have no knowledge that any interested person objects.
MPC 829 (8/27/12) NTCINT
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Docket No.
In the Interests of:
First Name
Middle Name
Last Name
SIGNED UNDER THE PENALTIES OF PERJURY
I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief.
Date:
Signature of Guardian
(Print name)
(Address)
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Primary Phone #:
Attorney for Guardian, if any
Signature of Attorney
(Print name)
(Address)
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Primary Phone #:
B.B.O. #
Email:
II. To be completed by authorized medical personnel only:
RECOMMENDATION FOR ADMISSION:
,
I,
print name
a licensed psychologist
a licensed physician
a nurse practitioner
a certified psychiatric nurse clinical specialist
recommend that the above-named Incapacitated Person be admitted to a nursing facility for
a period not to exceed sixty (60) days.
Date
Signature of Clinician
(Print name)
License type, number, and date
Office Address:
(Address)
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Office Phone:
MPC 829 (8/27/12) NTCINT
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