Get Behavioral Health Inpatient Discharge Form

Filling out the Behavioral Health Inpatient Discharge Form online is an essential process for ensuring a smooth transition after inpatient care. This guide provides clear instructions for completing each section of the form accurately and efficiently.

Follow the steps to complete the form online seamlessly.

1. Press the ‘Get Form’ button to obtain the Behavioral Health Inpatient Discharge Form and open it in your preferred editor.
2. Begin by entering the member information. Fill in the name, Amerigroup ID number, date of birth, address, city, state, and ZIP code. Ensure accuracy to avoid delays in processing.
3. Proceed to the provider information section. Input the facility name, National Provider Identifier (NPI) or Tax Identification Number (TIN), phone, date of admission, fax, and date of discharge.
4. Next, fill out the care coordination information. Provide details for the utilization manager (UM) including name, phone number, and fax number.
5. Complete the discharge information section. Include the discharge address and discharge phone number. If applicable, add any other relevant contact information.
6. Indicate whether the discharge was against medical advice, and if the discharge information was sent to the member’s primary care provider (PCP). Also, confirm if the discharge plan was discussed with the member.
7. If applicable for a minor, verify if informed consent for psychotherapeutic medication was completed and given to the parent or guardian.
8. List the formulary status of discharge medications by providing the name, dosage, frequency, and whether each medication is on formulary.
9. Confirm if preauthorization has been received for all medications, marking the appropriate box.
10. In the risk assessment section, indicate if the member was stable at discharge and provide an explanation if necessary.
11. Fill in the discharge appointments section, ensuring each appointment is scheduled within seven days. Include details for the in-network PCP, behavioral health provider, and any other providers.
12. Ensure that all additional required documentation, including the discharge summary, is ready to submit.
13. Lastly, enter your signature, date, phone, and fax before finalizing the form.
14. Once completed, save your changes, and you may download, print, or share the form as needed.

Complete the Behavioral Health Inpatient Discharge Form online to ensure timely processing and seamless transitions.