SECTION A
1. PATIENT’S NAME 2. HI CLAIM NUMBER
SECTION B (To be completed by attending physician)
IMPORTANT: Please supply all information requested in order that the reviewing physician may promptly process the claim. A copy of the patient’s chart
including a minimum of admission history and physical, admission nurse’s notes, all physician’s orders, progress notes, and discharge summary may be
submitted in addition to or in lieu of this form if it covers all information requested below.
1. Date and approximate hour when emergency
occured which resulted in hospital admission.
2. When and where was the patient first seen by you or another physician in connection with the emergency PRIOR
T
O ADMISSION TO THE HOSPITAL?
MO DAY YR. APPROXIMATE HOUR
MO DAY YR. APPROXIMATE HOUR
■ Home ■ Physician’s Office
■ Emergency Room ■ Accident Site
Other:
(Specify)
A.M. P.M.
A.M. P.M.
3. DATE AND HOUR OF ADMISSION ADMITTING DIAGNOSIS(ES)
4. Emergency services are defined in the Medicare program for purposes of payment as inpatient and outpatient hospital services which are necessary to prevent the
death or ser
ious impairment of the health of the individual and which, because of the threat to the life or health of the individual, necessitate the use of the most
accessible hospital available which is equipped to furnish such services.
In your opinion was this an emergency as defined under Medicare?
■ Ye s ■ No
5. List special equipment or special personnel available at the admitting hospital if such special equipment or special personnel was a factor in necessitating admission
there rather than to a hospital which participates in the Medicare program.
6. Indicate specific signs and symptoms of the patient at the time of initial examination which will help to justify this case as a Medicare emergency. (If the patient was
admitted because of a change in a chronic condition or a condition which existed for several days prior to admission, please indicate the ACUTE changes )
6.a. Other findings on hospital admission
■ Ambulatory ■ Conscious ■ Unconscious
■ Non-ambulatory ■ Semi-conscious ■ Pain - Yes ■ No Location of pain
Temperature Blood Pressure Pulse /min. Repirations /min.
Pertinent laboratory findings at that time
7. List specific emergency services and care including surgery and other procedures (i.e., cystoscopy, bronchoscopy, X-rays, etc.) provided during the hospital admission.
EMERGENCY SERVICE
DATE(S) RATIONALE OR REASON FOR SERVICE
(Do not list elective procedures or surgery)
Blood transfusion
■ Ye s ■ No
FORM CMS-1771 (9-77)
