CMS-100065/10066 Important Message from Medicare

{Insert contact information here}

Important Message from Medicare
Patient name:

Patient number:

Your Rights as a Hospital Inpatient:
• You can receive Medicare covered services. This includes medically necessary hospital
services and services you may need after you are discharged, if ordered by your doctor.
You have a right to know about these services, who will pay for them, and where you can
get them.
• You can be involved in any decisions about your hospital stay.
• You can report any concerns you have about the quality of care you receive to your QIO
at: {insert QIO name and toll-free number of QIO} The QIO is the independent reviewer
authorized by Medicare to review the decision to discharge you.
• You can work with the hospital to prepare for your safe discharge and arrange for
services you may need after you leave the hospital. When you no longer need inpatient
hospital care, your doctor or the hospital staff will inform you of your planned discharge
date.
• You can speak with your doctor or other hospital staff if you have concerns about being
discharged.

Your Right to Appeal Your Hospital Discharge:
• You have the right to an immediate, independent medical review (appeal) of the
decision to discharge you from the hospital. If you do this, you will not have to pay for
the services you receive during the appeal (except for charges like copays and
deductibles).
• If you choose to appeal, the independent reviewer will ask for your opinion. The
reviewer also will look at your medical records and/or other relevant information. You
do not have to prepare anything in writing, but you have the right to do so if you wish.
• If you choose to appeal, you and the reviewer will each receive a copy of a detailed
explanation about why your covered hospital stay should not continue. You will
receive this detailed notice only after you request an appeal.
• If the QIO finds that you are not ready to be discharged from the hospital, Medicare
will continue to cover your hospital services.
• If the QIO agrees services should no longer be covered after the discharge date,
neither Medicare nor your Medicare health plan will pay for your hospital stay after
noon of the day after the QIO notifies you of its decision. If you stop services no later
than that time, you will avoid financial liability.
• If you do not appeal, you may have to pay for any services you receive after your
discharge date.
Form CMS 10065-IM (Exp. xx/xx/xxxx)

OMB approval 0938-xxxx

See page 2 of this notice for more information.

How to Ask For an Appeal of your Hospital Discharge
• You must make your request to the QIO listed above.
• Your request for an appeal should be made as soon as possible, but no later than
your planned discharge date and before you leave the hospital.
• The QIO will notify you of its decision as soon as possible, generally no later than 1
day after it receives all necessary information.
• Call the QIO listed on Page 1 to appeal, or if you have questions.

If You Miss The Deadline to Request An Appeal, You May Have Other Appeal
Rights:
• If you have Original Medicare: Call the QIO listed on Page 1.
• If you belong to a Medicare health plan: Call your plan at {insert plan name and toll-free
number of plan}
For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048.
CMS does not discriminate in its programs and activities. To request this publication in an
alternate format, please call: 1-800-MEDICARE or email: [email protected] .

Additional Information (Optional):

Please sign below to indicate you received and understood this notice.
I have been notified of my rights as a hospital inpatient and that I may appeal my
discharge by contacting my QIO.

Signature of Patient or Representative

Date

/ Time

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- 0692. The time required to complete this information collection is estimated to average 15 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.

Form CMS 10065-IM (Exp. xx/xx/xxxx)

OMB approval 0938-xxxx