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Instructions for Completing
NOTICE OF INTENT TO ADMIT
TO A NURSING FACILITY
FOR SHORT TERM SERVICES (MPC 829)
orm Use:
his form may be used ONLY to authorize a court appointed guardian to admit an incapacitated person to a
nursing facility for a period of sixty (60) days or less, without prior court approval, if the incapacitated person
and persons interested in the welfare of the incapacitated person do not object to such short term admission.
If the admission is anticipated to be more than 60 days or will not occur within seven (7) days of filing this
form, then court approval must be sought.
ho May Use this Form:
ppointment of Counsel:
nly a Massachusetts court appointed guardian, temporary or permanent, may use this form.
he incapacitated person must be represented by counsel. If the incapacitated person is not already
represented by counsel, the court shall appoint counsel forthwith upon the filing of this notice with the Court.
The incapacitated person may be admitted to the nursing facility upon the filing of this notice with the Court,
and pending appointment of counsel.
ecommendation for Admission:
licensed physician, licensed psychologist, certified psychiatric nurse clinical specialist or nurse
practitioner must recommend admission to the nursing facility by providing his/her endorsement on the
form. A medical certificate is not required.
equired Notice:
n or before the date of admission, the guardian shall serve a signed copy of the Notice of Intent to Admit to
a Nursing Facility for Short Term Services (MPC 829) form in-hand on the incapacitated person, and provide
a signed copy to the nursing facility either in-hand, by facsimile or by email. If counsel has already been
appointed to represent the incapacitated person, the guardian shall also provide a signed copy of the
completed form, on or before the date of admission, to counsel either in-hand or by facsimile. If the
incapacitated person is not yet represented by counsel, the guardian shall provide a signed copy of this form
to counsel upon his/her appointment in the same manner. Proof of service is not required to be filed with the
Court, but may be requested at any time. See Rule 3 of the Supplemental Rules of the Probate and Family
Court for a guardian’s duty to provide notice to counsel for the incapacitated person.
iling Fee:
one.
iling with the Court:
nce the form is completed, signed, and notice is provided as indicated above, the form must be filed in the
Court where the guardian was appointed on or before the date of admission. The form shall be considered
“filed” when it has either been docketed or date stamped as received by the Division where the guardian was
appointed. A hearing is not required and no other action will be taken by the Court except appointment of
counsel, if necessary. Once filed, a copy of the form may be requested upon payment of $1.00 per page or
$2.50 per page for a copy attested to by the Register of Probate.
MPC 955 (8/15/12)
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To Complete this Form:
CAPTION:
Person).
ase Name: Enter the name of the case (Example: In the Interests of Donna Jane Doe, Incapacitated
ocket Number: Fill in the docket number assigned by the Court to the guardianship appointment.
ivision: Enter the name and address of the Probate and Family Court where the guardian was appointed
and where this form will be filed (Example: Suffolk Division, 24 New Chardon Street, Boston, MA 02114,
etc).
SECTION I. To Be Completed by Guardian:
ame and Address of Nursing Facility: Enter the name and address of the specific nursing facility where
the incapacitated person will be admitted. **IMPORTANT NOTE: If this information is unknown, this form
cannot be used.
xpected Date of Admission: Enter the expected date of admission to the nursing facility.
**IMPORTANT NOTE: In order to use this form, admission to the nursing facility must not be a mere
possibility in the future. Admission to the nursing facility must occur within seven (7) days of filing this form
with the Court or this form cannot be used.
xpected Date of Discharge: Enter the expected date of discharge from the nursing facility.
**IMPORTANT NOTE: The expected date of discharge cannot be more than sixty (60) days from the date of
admission to the nursing facility.
ppointment of Counsel: In # 4, select the appropriate box to indicate if the incapacitated person is
represented by counsel. If yes, check box “(a)” and enter the name of counsel. NOTE: It is the responsibility
of the guardian to enter this information. This information is public record and may be verified or obtained by
reviewing the case file in person. The Probate and Family Court does not have resources to verify this
information by telephone.
f the incapacitated person is NOT already represented by counsel, check box “(b)”. **IMPORTANT NOTE:
In order to use this form, the incapacitated person must be represented by counsel. If the incapacitated
person is not already represented by counsel, an immediate appointment must be made by the Court upon
filing this form.
erification by Guardian: The guardian must sign his or her name, under the penalties of perjury, where
indicated and CLEARLY PRINT his/her name below his/her signature and date the form in the appropriate
space to the left. Enter the guardian’s current address, including zip code and primary phone number, in the
space provided. Information about the guardian’s attorney, if any, shall also be provided.
SECTION II. To Be Completed by Authorized Medical Personnel Only:
ECOMMENDATION FOR ADMISSION:
n order for a Massachusetts court appointed guardian to admit an incapacitated person to a nursing facility
for a period of sixty (60) days or less without prior court approval, G. L. c. 190B, § 5-309(g) requires and
authorizes a licensed physician, licensed psychologist, certified psychiatric nurse clinical specialist or nurse
practitioner to recommend admission to the nursing facility. As an authorized medical provider, you are being
requested by the guardian to recommend such admission. **IMPORTANT NOTE: If you are not able to
recommend an admission for sixty (60) days or less, do not sign this form.
o recommend admission, print your name in the space provided, sign where indicated, and date the form in
the appropriate space. Please provide your office address and phone number and enter your license type,
number and date in the space provided.
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MPC 955 (8/15/12)
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