Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges : Important Message From Medicare

Notice Instructions

The Important Message from Medicare (OMB #0938-0692)

Completing the Notice

PAGE 1 of the Important Message from Medicare

A. Header

Hospitals must display the CMS logo and OMB number.

The following blanks must be completed by the hospital. Information inserted by hospitals in the blank spaces on the IM may be typed or legibly hand-written. Hospitals may also use a patient label which includes the following information:

Patient Name: Fill in the patient’s full name.

Patient ID number: Fill in an ID number that identifies this patient. This number should not be, nor should it contain, the social security number.

Attending Physician: Fill in the patient’s attending physician’s name.

2. Body of the Notice

To speak with someone at the hospital about this notice call: Fill in a contact name and telephone number of a person at the hospital for the patient to call with questions about the notice.

Patient or Representative Signature: Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents.

Date: Have the patient or representative place the date he or she signed the notice.

PAGE 2 of the Important Message from Medicare

{Insert name and telephone number of QIO in BOLD}: Insert name and telephone number (including TTY), in bold, of the Quality Improvement Organization that performs reviews for the hospital.

Additional Information: Hospitals may use this section for additional documentation, including, for example, obtaining beneficiary initials to document delivery of the follow-up copy of the IM.