CMS-10065/10066 Detailed Notice of Discharge

{Insert contact information here}

Detailed Notice of Discharge
Date:

Patient name:

Patient number:

This notice gives a detailed explanation of why your hospital or Medicare health plan has
determined Medicare coverage for your hospital stay should end. This notice is not the
decision on your appeal. The decision on your appeal will come from your Quality
Improvement Organization (QIO).
We have reviewed your case and decided that Medicare coverage of your hospital stay
should end.
•

The facts used to make this decision:

•

Detailed explanation of why your hospital stay is no longer covered, and the specific
Medicare coverage rules and policy used to make this decision:

•

Plan policy, provision, or rationale used in making the decision (health plans only):

If you would like a copy of the policy or coverage guidelines used to make this
decision, or a copy of the documents sent to the QIO, please call us at:
{insert hospital/Medicare health plan name and toll-free 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 0938-1019. 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 10066-DND (Exp. xx/xx/2xx)

OMB approval 0938-1019