Form CMS-10066 DETAILED NOTICE OF DISCHARGE

OMB Approval No. 0938-NEW

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DETAILED NOTICE OF DISCHARGE

Patient Name__________________________ Patient ID Number__________________

Attending Physician_____________________ Date Issued_______________________

This notice gives you a detailed explanation of why your hospital and doctor (and/or your managed care plan, if you belong to one) believe your hospital services should end on ______________________________, based on Medicare coverage policies and medical judgment. This is not an official Medicare decision. The decision on your appeal will come from your Quality Improvement Organization (QIO).

• The facts used to make this decision:

• Explanation of Medicare coverage policies that we used to determine that Medicare will no longer cover your hospital stay:

• If applicable, Medicare managed care policies, provisions, or rationale used to make this decision:

If you would like a copy of the Medicare coverage policies or Medicare managed care plan policies used to make this decision, or a copy of the documents sent to the QIO, please call us at {insert hospital and/or plan telephone number}.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- NEW. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

DRAFT