Patient Discharge Document

PATIENT DISCHARGE DOCUMENT

This Patient Discharge Document is entered into by and between Provider Name: Provider Address:

and Patient Name: Patient Address:

Effective Date:

WHEREAS

WHEREAS, Provider is a licensed health care provider authorized to render medical and related services to patients and has provided inpatient and/or outpatient care to Patient during the period referenced in this Document;

WHEREAS, Patient has received treatment, evaluation and/or procedures and is medically suitable for discharge from the site of care in accordance with Provider's standard of care and applicable clinical criteria;

WHEREAS, the parties wish to document the instructions, post-discharge plan, financial responsibilities, and legal acknowledgments associated with Patient's discharge.

DISCHARGE SUMMARY

Medical Record No.: Date of Birth:

Admission Date: Discharge Date:

Stable Improved Requires assistance at home Other:

DISCHARGE INSTRUCTIONS

Follow-up Appointment Date: Time: Location / Provider:

SCOPE OF WORK

The parties agree that Provider's obligations with respect to Patient during the discharge process include, without limitation, the provision of medical summary documentation, discharge instructions, medication reconciliation, coordination of necessary aftercare referrals, and any listed post-discharge services below. Any additional services requested by Patient that are outside customary discharge duties shall be subject to separate written agreement.

PAYMENT TERMS

Patient acknowledges responsibility for charges for care and services provided by Provider that are not otherwise covered by insurance or third-party payors. Provider will bill Patient or Patient's responsible party in accordance with Provider's billing practices.

Late Payment Fee:

TERM AND TERMINATION

This Document applies to the period beginning on and ending on , unless earlier terminated in accordance with this section.

Either party may terminate this Document for material breach by the other party following written notice and a cure period of days. Termination shall not relieve Patient of financial obligations for services already rendered.

CONFIDENTIALITY

All protected health information (PHI) and medical records created or maintained in connection with the care described herein remain subject to applicable law governing privacy and confidentiality. Provider will release PHI only as required by law or with Patient's written authorization, except as necessary to effectuate aftercare, referrals, billing and coordination with authorized third-party payors. Patient authorizes release of necessary information to such parties for those purposes.

GOVERNING LAW

This Document shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts-of-law principles.

ENTIRE AGREEMENT

This Document, together with any written attachments or post-discharge orders expressly referenced herein, constitutes the entire agreement between Provider and Patient with respect to the subject matter hereof and supersedes all prior agreements, promises, representations and understandings, whether written or oral.

PATIENT ACKNOWLEDGMENT

By signing below, Patient acknowledges that Provider has explained the discharge instructions, medications, follow-up arrangements, and whom to contact in an emergency. Patient further acknowledges receipt of copies of discharge summaries and instructions, and that questions have been addressed to Patient's reasonable satisfaction.

Patient acknowledges: I received a written copy of my discharge instructions. I understand the instructions.

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