Behavioral Health Inpatient Discharge Form 2026

1. Click ‘Get Form’ to open the Behavioral Health Inpatient Discharge Form in the editor.
2. Begin by filling out the Member Information section. Enter the member's name, Amerigroup ID number, date of birth, address, city, state, and ZIP code accurately.
3. Next, complete the Provider Information section. Input the facility name, NPI/TIN, phone number, date of admission, fax number, and date of discharge.
4. In the Care Coordination section, provide details for the Utilization Manager (UM), including their name and contact information.
5. Fill out the Discharge Information section. Include discharge address and phone number. Indicate if the discharge was against medical advice and whether discharge information was sent to the member’s PCP.
6. Complete the Formulary Status of Discharge Medications by listing each medication's name, dosage, frequency, and formulary status.
7. Assess risk by answering whether the member was stable at discharge. If not stable, provide an explanation.
8. Schedule discharge appointments within seven days by providing details for in-network providers including names and appointment times.
9. Finally, ensure all required documentation is attached before signing and dating the form at the bottom.

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