TX HHS Form 8625-D. Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge

The TX HHS Form 8625-D, Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Nursing Facility Discharge, is a crucial document for resolving conflicts between nursing facility residents and the facilities themselves. This form enables a resident who disagrees with a facility's decision to discharge them to designate a long-term care ombudsman as their representative in the appeal process.

The form requires the resident or their designated representative to provide essential information, including the resident's name, address, date of birth, and social security number. The ombudsman must also be identified, along with their contact details. The resident can choose one of three options for the ombudsman's role: representing them throughout the hearing process, acting as a witness at their hearing, or obtaining information about their hearing on their behalf.

To submit this form, the ombudsman must include a copy of the discharge notice, the reason for disagreeing with the facility's decision, any requested accommodations for the hearing (including an interpreter), and the names and addresses of any witnesses. The State Ombudsman may sign the form on behalf of the resident if they lack capacity to consent or have no available legally authorized representative.

• This form is used when a nursing facility resident disagrees with their discharge decision and wants to appeal it.
• The form requires the resident's identification information, as well as that of the designated ombudsman.
• The ombudsman must provide contact details and may sign the form on behalf of the resident if necessary.