Healthcare CMS Report

Healthcare CMS Report

Reporting Facility / Provider

Patient Information

Patient Name:    Date of Birth:    Gender: Female Male Other

Insurance Information

Clinical Summary and Measures

Admission Date:    Discharge Date:    Procedure Date:

Medication reconciliation at discharge documented
Readmission within 30 days reported
Sepsis bundle adherence documented
Vaccination status documented where applicable

Adverse Event / Incident Report

Incident Occurred: Yes No    Incident Date:

Attachments and Supporting Documentation

Attachments included with this report (check all that apply):
Discharge summary
Operative/procedure note
Laboratory results
Imaging reports
Other (describe below)

Authorization and Privacy Acknowledgment

By signing below, I authorize the release of the protected health information and clinical data contained in this report to authorized reviewers for the purpose of regulatory review, quality assessment, payment determination, and other lawful oversight activities. I understand that information disclosed pursuant to this authorization may include medical history, diagnoses, treatment records, and other relevant clinical information necessary for review.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on:

I acknowledge receipt of the facility's privacy notice and understand my rights regarding the privacy of my health information under applicable law. I understand that information disclosed under this authorization may be subject to re-disclosure by a recipient and may no longer be protected by privacy laws.

Certification and Attestation

I certify that the information provided in this Healthcare CMS Report is true, complete, and accurate to the best of my knowledge. I attest that I am authorized to request release of the information described herein and that records submitted are derived from the patient's medical record and clinical documentation maintained by the reporting facility.

I understand that knowingly submitting false information may subject the submitter to civil, administrative, or criminal penalties under applicable law, and I will cooperate with any follow-up inquiries to verify the accuracy of the reported information.

HIPAA Acknowledgment

I acknowledge that I have been informed of my privacy rights and the uses and disclosures that may be made of my protected health information in connection with this report. I further acknowledge that I have had the opportunity to ask questions regarding this notice.

Acknowledged: Yes

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