1. (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).
2. (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).
3. (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).
4. (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).
5. (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.

Source. #13130, eff 10-30-20 (formerly He-E 802.18)