Maine DHHS Provider Portal

Transfers For MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
* = Required Field

Member Information
First Name:	* Required Field *
Middle Name:
Last Name:	* Required Field *
MaineCare #: (12345678A or 12345678T)	* 12345678A or 12345678T * Required Field *
Facility/Agency Information
Facility Name:	Type your facility name only if it is not in the drop-down list.
Phone: (xxx-xxx-xxxx)	* Required Field * Invalid phone number *
Fax: (xxx-xxx-xxxx)	* Invalid fax number *
Contact Name:
E-Mail:	Invalid e-mail address *

Transferred to:
	Hospital: Bedhold Request (Required if hospital stay > 24 hours) Hospital Name: Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 * Time: (HH:MM am/pm) (HH:MM am/pm) * You must enter a time
	Your nursing facility from hospital
	to SNF Medicare Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 *
	to NF MaineCare Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 *
	from SNF Medicare back to NF MaineCare First non-SNF Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 *
	Medicare Advantage participant - SNF Benefit
	End: Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 * End date must be > start dateInvalid date: use mm/dd/yyyy
	from NF MaineCare to SNF Medicare within 30 days of admit Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 *
	from NF MaineCare to Private pay Date: (mm/dd/yyyy and before today's date) Invalid date: use mm/dd/yyyy and must be on or before 12/26/2024 *

Aging & Disability Services