Healthcare Closure Report

HEALTHCARE CLOSURE REPORT

Patient Information

Patient Name:   Medical Record No.:

Date of Birth:   Gender:

Insurance Information

Closure Details

Date of Closure:   Admitting Date:

Closure Type:    Discharge to home    Transfer to facility    Deceased    Left AMA    Administrative closure

Outcome / Status at Closure:    Stable    Improved    Unresolved/Requires follow-up    Referred

Clinical Information at Closure

Follow-up and Referral Information

Follow-up Appointment Scheduled:   Prescription Provided: Yes   Transportation Arranged: Yes

Notifications & Administrative Status

Primary Care Provider Notified: Yes   Date Notified:

Family/Representative Notified: Yes   Name/Relationship:

Payer/Billing Notified: Yes   Billing Status:

Authorization for Release of Records

By initialing and signing below, the patient authorizes the facility to release relevant medical records to the receiving provider or other designated parties as required for continuity of care. This authorization includes summaries, discharge instructions, medication lists, and pending test results. The authorization does not authorize release of psychotherapy notes unless separately signed.

Authorization Expiration Date:

Patient Acknowledgement: I acknowledge I have received a verbal and written summary of the closure, understand follow-up instructions, and consent to the transfer of records as indicated above.

Provider / Reporter Information

Report Completed Date:

Acknowledgment and Certification

Certification: I certify that the information contained in this closure report is true and accurate to the best of my knowledge. I understand that this report becomes part of the official medical record and may be used for continuity of care, billing, and administrative purposes. I acknowledge my right to request amendment or obtain copies of my medical record in accordance with applicable privacy laws.

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