• Hospital Discharge Form

  • Basic Information

  • Complete this form for all hospital discharges. Refer to Hospital Discharge Summary Form Instructions for information on how to complete this form.

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    Pick a Date

  • Medical Information

  • 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)

  •  - -Pick a Date
  • Other Information

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  • Should be Empty: