Substance Abuse Discharge Note - Providers - Select Health of 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering today’s date at the top of the form. This is essential for record-keeping.
3. Fill in the contact information section, including the member's name, ID number, date of birth, and phone number.
4. Provide details about the facility, including its name and NPI/Provider Number, as well as admission and discharge dates.
5. Indicate where the member is being discharged to (home, shelter, etc.) and provide their discharge address and phone number.
6. If applicable, include contact information for a parent or guardian if the member is a minor or dependent adult.
7. Complete the ICD-10 discharge diagnoses section and indicate whether the discharge was against medical advice (AMA).
8. Answer questions regarding communication with primary care providers and discuss discharge plans with members.
9. Fill out ASAM ratings for each dimension by providing explanations as required.
10. Document any medications prescribed at discharge along with their details and check formulary status.
11. Assess risk stability at discharge and schedule aftercare appointments within seven days if necessary.
12. Finally, ensure that all sections are completed before submitting the form along with your contact information.

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