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Get Behavioral Health Inpatient Discharge Form

X at 1-877-434-7578. If you have any questions, please contact Provider Services at 1-800-454-3730. Member information Name: Amerigroup ID number: DOB: Address: City, State: ZIP code: Provider information Facility name: NPI/TIN: Phone: Date of admission: Fax: Date of discharge: Care Coordination Utilization manager (UM): UM phone: UM fax: Discharge information Discharge address: Discharge phone: Other contact information (e.g., mobile phone, family member or guardian)? Was this discha.

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