Status Change for Residents in a Rest Home (Admission or Discharge of SSI Recipients) SECTION 1 1. Rest Home ID/Service Location 2. Name of Rest Home 3. Telephone No. of Rest Home 4. Address of Rest Home 5. Resident Last Name 6. Resident First Name 7. Middle Initial 8. Resident Home Address 9. Resident Date of Birth / / 10. Resident Gender Female Male 11. Member ID or SSN (Provide SSN only if member ID is not available.) SECTION 2 12. Type of Status Change Admit Discharge Both admit and discharge 13. Admitted From Home/community Hospital Nursing facility Rest home 14. Admission Date / / 15. Discharge Date / / 16. Discharge Reason Discharged to home/community Discharged to a rest home Other (explain): Discharged to a hospital Left against medical advice Discharged to a long-term-care facility Deceased. Date of death: / / SECTION 3 17. Requested Payment Date / / 18. Signature of authorized representative completing the SC-1-RH form. 19. Date / / INSTRUCTIONS FOR COMPLETING THE SC-1-RH FORM (PLEASE PRINT OR TYPE.) Below are instructions for specific fields. All other fields are self-explanatory. For all items with check boxes, please make sure you check one box. SECTION 1 Item 1 Rest Home ID/Service Location Enter the nine-digit provider ID followed by the one-character location code. Item 11 Member ID or SSN Enter the 12-digit MassHealth member ID number. Enter the social security number (SSN) only if member ID is not available. SECTION 2 Item 16 Discharge Reason Includes home/community, hospital, long-term-care facility, rest home, or left against medical advice. If selecting deceased, enter the date of death. If reason is any other, explain the reason in the space provided. SECTION 3 Item 17 Requested Payment Date Enter the start date for which payment is requested. SC-1-RH (05/09)