Behavioral health discharge form 2026

1. Click ‘Get Form’ to open the behavioral health discharge form in the editor.
2. Begin by entering today’s date at the top of the form. This is crucial for record-keeping.
3. Fill in the member's name, ID number, date of birth, address, and phone number. Ensure accuracy as this information is vital for identification.
4. Provide details about the facility including its name and NPI/Amerigroup provider number.
5. Indicate the date of discharge and provide a discharge address and phone number for follow-up.
6. Answer whether the discharge was against medical advice (AMA) and if discharge information was sent to the PCP/psychiatrist.
7. Check all applicable items included in the discharge plan, such as skilled nursing facilities or community support services.
8. List any discharge medications along with their doses and confirm if they require precertification.
9. Complete risk assessment questions regarding member stability at discharge.
10. Schedule a follow-up appointment within seven days by filling in provider details and appointment time.

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