Hospital Discharge Forms Download PDF Details

Are you one of those people who dreads filling out hospital discharge forms? If so, you're not alone. These documents can be confusing and time-consuming to complete. However, with the right tools, you can make the process a little easier. The Hospital Discharge Forms Download from FormDownloader.com provides everything you need to get your paperwork handled quickly and easily. This downloadable package includes all the forms you'll need to leave the hospital, including a release form for your doctor, a post-hospital care plan, and more. Plus, our helpful guide will walk you through each step of the process so that you can minimize any hassle or stress.

Listed below are some specifics of hospital discharge forms download. This figure can provide details about the form's size, finalization time, and the areas you're needed to fill.

QuestionAnswer
Form NameHospital Discharge Forms Download
Form Length2 pages
Fillable?Yes
Fillable fields50
Avg. time to fill out10 min 34 sec
Other names Fillable Online www5 esc13 Speaker Proposal Form - www5 ...

Form Preview Example

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 TMP_Appeals_Requests@tufts-health.com

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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