Aging & Disability Services

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

Hospital: (Required if hospital stay > 24 hours)   Hospital Name:   Admit Date: Invalid date: use mm/dd/yyyy and must be before today's date   Return to PNMI/AFCH Date:

Nursing Facility:   Name:   Admit Date: Invalid date: use mm/dd/yyyy <= today   Return to PNMI/AFCH Date: Invalid date: use mm/dd/yyyy <= today

Leave Day Initial Request - Medical   Start Date: Invalid date: use mm/dd/yyyy   End Date: Invalid date: use mm/dd/yyyy

Leave Day Extension Request - Medical   Start Date: Invalid date: use mm/dd/yyyy   End Date: Invalid date: use mm/dd/yyyy

	Leave Day Request - Nonmedical   Start Date: Invalid date: use mm/dd/yyyy   End Date: Invalid date: use mm/dd/yyyy
Not Selected Vacation Home Stay Other (Specify):