Get 267tpl

Filling out the 267tpl form online is a straightforward process that requires careful attention to details. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to complete the 267tpl form online.

1. Click the ‘Get Form’ button to access the 267tpl form and open it in a user-friendly editor.
2. Begin by entering your information in the 'TO' and 'FROM' sections. Provide the name of the agency or department you are notifying and the facility's name and address.
3. In the admission section, fill in the client name, recipient number, case number, Social Security number, and birthdate as required.
4. Check the appropriate box if you are reporting an admission and enter the admission date along with the previous address. Indicate whether the client receives hospice services.
5. For the admitting diagnosis, enter the appropriate ICD-9 code. Include the attending physician's name and their identification number, noting that a signature is not required.
6. Move to the discharge section if applicable. Provide the discharge date and new address, along with the destination of discharge and any relevant details.
7. If reporting a death, complete the relevant sections including the date of death and who the body was released to.
8. In the financial sections, document the personal funds balance, room and board balance, and any disbursements made following the discharge or death.
9. Complete the sections regarding income changes. Indicate the previous and current monthly income amounts along with the sources.
10. Address any insurance coverage changes by detailing new or altered coverage in the appropriate sections.
11. Finally, review the form for completeness. Ensure that all required fields are filled out, and then save your changes. You can download, print, or share the completed form as needed.

Take action now and complete the 267tpl form online to ensure your submission is processed promptly.