Aftercare Appointment (s)
Provider Name Provider Type Date Date
Medicare Advantage Notice of Discharge
Inpatient Behavioral Health Hospitalization
City: State: Zip:
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Admission Date: DC Date:
DC Planner name:
DC Housing type:
(Home alone, home w/ family/friends, nursing home, personal care/boarding home, etc).
Is this a new living arrangement?
DC Phone #:
If no aftercare appointment is scheduled, please explain:
Other discharge plan comments:
Diagnosis ICD 10 Codes
Medication Dosage Frequency
Fax to Behavioral Health Unit: 866-949-4846
Please complete and fax this form on the same day of discharge.