Tential beneficiary). It must be completed for potentially eligible Medicaid beneficiaries of all ages. The facility must retain THE ORIGINAL of the Facility Admission Notice in the beneficiary's file. A copy MUST be sent to the Local DHS Office. A copy of the MSA-2565-C will be returned to the facility, noting the eligibility status and patient pay amount of the resident. Authority: Completion: Penalty: P.A. 280 of 1939 and Federal 42 CFR of 435 Title XIX of the Social Security Ac.
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How to fill out the 2565 Facility Admission Notice online
Completing the 2565 Facility Admission Notice is an essential step for ensuring proper admission of a beneficiary to a facility. This guide will provide clear, step-by-step instructions to assist you in filling out this document accurately and efficiently online.
Follow the steps to complete the Facility Admission Notice.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient's name in the format of Last, First, Middle in field 1.
- Indicate the patient's gender by checking 'M' for male or 'F' for female in field 2.
- Fill in the patient's birth date in field 3, using the format MM/DD/YYYY.
- In field 4, provide the patient's Social Security number using the specified format.
- Enter the home address of the patient, including street number, apartment number (if applicable), city, state, and zip code in fields 5, 6, 7, and 8.
- Document the name of the person responsible for the patient in field 6, along with their relationship to the patient in field 8.
- In field 9, fill out the phone number of the responsible person.
- Provide details about the facility in sections 10 to 15, including the provider name, provider address, attending physician's name, facility type, and the date of admission.
- Indicate if the admission is likely to be 30 days or longer in field 18, and estimate the total length of stay if applicable.
- Document the patient's present status in field 19, and provide primary and secondary diagnosis in fields 20 and 21.
- Indicate the source of the patient's admission in field 22.
- Provide information regarding Medicare or private health insurance in fields 23 to 35, as applicable.
- Ensure the Patient Certification section is completed and signed by the patient or their representative in fields 36 and 37.
- Finally, review all entries for accuracy, then save your changes, download, print, or share the form as needed.
Complete the 2565 Facility Admission Notice online today to ensure a smooth admission process.
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