Hospital Discharge Summary Form Instructions

Hospital Discharge Summary Form
Complete this form for all hospital discharges. Refer to Hospital Discharge Summary Form Instructions
for information on how to complete this form.
Securely email completed form to [email protected]
I: Member name______________________________________ I.D.# _________________________

CM/DCM name _________________________ Phone # ____________________ Fax # ___________
PCP name ____________________________________ Medical group/IPA #____________________
Facility name _______________________________ Attending physician _______________________
II: Date Services should end: __________________

III: Elements that need to be put in place prior to discharge (verify that the following information is
documented in the record, if applicable)
Physician note reflecting readiness for discharge Discharge plan discussed with attending provider
Discharge plan discussed with member/family Description of discharge plan in place
Therapy notes (if applicable) Other (please be specific) __________________
IV: Applicable Medicare coverage policies (please select one)
Medicare does not cover inpatient hospital services that are not medically necessary or could be safely furnished
in another setting (refer to 42 Code of Federal Regulations, 411.15 (g) and (k)
Medicare Managed Care policies, if applicable (List specific managed care policies) _______________________
____________________________________________________________________________________________
Other (List other applicable policies) ____________________________________________________________
____________________________________________________________________________________________
V: Fill in detailed and specific information about the patient’s current medical condition and the
reasons why services are no longer reasonable or necessary for this patient or are no longer covered
according to Medicare or Medicare managed care coverage guidelines. (Use full sentences, plain
language and no abbreviations):
1. You were admitted to (see facility above) on the following date ________________
2. At admission you presented with the following symptoms:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. You were diagnosed with
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. You were treated with
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. Your tests were (include results)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
6. You were evaluated by
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Revised 02/2015 1 Hospital Discharge Summary Form
2113379
7. You are now (list current treatment plan and/or state the medical issue is resolved)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
8. Your provider feels that your condition has improved and that the care you need now could safely
be provided in/at
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
9. Your discharge plan and follow-up care includes
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
VI: Printed name of person completing the form __________________________________________
Signature of person completing the form ________________________________________________
Phone # ___________________________________ Fax # _________________________________
Provider Relations
Revised 02/2015 2 Hospital Discharge Summary Form

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Hospital Discharge Summary Form

I: Member name______________ I.D.# _

II: Date Services should end: __________________

Revised 02/2015 2 Hospital Discharge Summary Form

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