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  • Behavioral Health Inpatient Discharge Form

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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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It includes information on patient history and social context, medications, the details of their hospital admission, as well as current and previous diagnoses. The mental health discharge summary will improve professional communication between the patient's secondary care providers to their GP.

Detailed reasons for reasons for discharge (including progress toward treatment goals) Any risk factors at the time care ended. Referrals and resources of benefit to the client.

To write a discharge note we can include: Reasons for termination, including referrals to new providers. Symptoms at the time of intake. Initial reasons for seeking treatment. Diagnosis. Treatment goals, past and present. Modalities and interventions used and how the client responded.

A Good Discharge summary will contain. . . Encounter Location/Organzation. Hospital name and service(s) accessed by patient. Diagnosis. ... Course While In Hospital. Concise description of patient's initial presentation. Treatment provided and results of procedures. ... Discharge Plan. Categorized listing of medications (e.g. home vs.

The purpose of a termination summary is for professional communication. After termination, your client may request a copy of their therapy records. The request may be for legal purposes, for a subsequent therapist, or for medical records of some kind.

You have the right to discharge yourself from hospital at any time during your stay in hospital. If you want to complain about how a hospital discharge was handled, speak to the staff involved to see if the problem can be resolved informally.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232