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Type of discharge in hospital

How to fill discharge form for patient 2011-2026

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The document is a fax assessment form for the UAW Retiree Medical Benefits Trust, specifically for Medicare Plus Blue PPO skilled nursing and acute rehabilitation facilities. It outlines the requirements for precertification and recertification, including necessary clinical information, facility details, and patient data. The form emphasizes the importance of completeness and legibility in submissions to avoid processing delays and includes disclaimers regarding therapy requirements and payment guarantees.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the MEMBER/FACILITY INFORMATION section. Enter the member's name, contract number, phone number, and admission date. Ensure all information is legible.
In the CLINICAL INFORMATION/BASICS section, provide vital signs and medical history. Include details about bowel and bladder function, as well as any surgical procedures that have occurred.
Complete the MOBILITY CURRENT FUNCTIONING section by indicating the level of assistance required for various activities such as transfers and gait. Be specific about assistive devices used.
Fill out the DISCHARGE (DC) PLANS section with tentative discharge dates and home evaluation details. Specify any equipment needed and supervision requirements.

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