Follow the steps to complete the Discharge Note Fax Form online.

1. Press the ‘Get Form’ button to access the Discharge Note Fax Form and open it in your editing interface.
2. Enter today’s date in the specified field to provide a reference for the discharge documentation.
3. Complete the contact information section by filling out the member's name, member ID or reference number, date of birth, address, and phone number.
4. Provide the name of the facility from which the member is being discharged and include the facility's NPI or Amerigroup provider number.
5. Indicate the date of discharge, discharge address, and discharge phone number for follow-up communications.
6. If applicable, include any other contact information, such as a mobile phone number or details of a family member or guardian.
7. Answer whether the discharge was Against Medical Advice (AMA) by selecting 'Yes' or 'No'.
8. Indicate if the discharge information was sent to the primary care provider (PCP) by selecting 'Yes' or 'No'.
9. Confirm if the discharge plan was discussed with the member through the relevant options.
10. If the member is a minor, indicate whether informed consent for psychotherapeutic medication was obtained from a parent or guardian.
11. Check all applicable items included in the discharge plan, ensuring to provide clear selections for each option.
12. Detail the discharge diagnosis by completing all five axes (Axis I to Axis V) thoroughly.
13. List all discharge medications, including names and doses for all conditions being treated.
14. Determine if any medications require precertification and indicate if precertification has been received.
15. Conduct a risk assessment to confirm if the member was stable at discharge, indicating no risk for suicide, homicide, or psychosis.
16. Document the details for the discharge appointment, ensuring it is scheduled within seven days, and include provider name, contract number, tax ID, and network status.
17. Fill out the date and time of the appointment while addressing any potential barriers to attending the scheduled appointment.
18. Finally, submit your name and phone number in the 'Submitted by' section, confirming your role in the discharge process.
19. After thoroughly reviewing the completed form, save any changes made, and utilize options to download, print, or share the form as needed.

Complete the Discharge Note Fax Form online today to support seamless care transitions.