Discharge Form

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Instructions

Only providers with prescriptive authority can use this form. Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Patient Information

Patient's First Name

Patient's Last Name

ID Card Number

Phone Area Code () First Three Digits - Last Four Digits

Facility's Name

Diagnosis

You must use ICD-10 codes. ICD-10 codes can be three, six or seven characters. Please ensure you use the correct codes.

Primary Diagnosis

Current Height

Current Weight

Weight Loss/Gain in lbs

Weight Loss/Gain in Last Months

Comments Regarding Medical Issues Related to Eating Disorders Max characters: 200

Primary Diagnosis 2 Remove

Primary Diagnosis 3 Remove

Additional Diagnosis Add

Additional Diagnosis 2 Remove

Additional Diagnosis 3 Remove

Hidden

Hidden Remove

Hidden

Hidden Remove

Hidden

Axis V Initial GAF

Axis V Current GAF

Information Provided By:

Date of Admission

Date of Discharge

Actual Length of Stay:

Discharge Living Arrangements:

If yes, please provide date:

Follow-up Information

If no, what is the reason:

Psychiatrist Information:

Psychiatrist First Name:

Psychiatrist Last Name:

Psychiatrist Phone: Area Code () First Three Digits - Last Four Digits

Psychiatrist Date:

Therapist's Information:

Therapist First Name:

Therapist Last Name:

Therapist Phone: Area Code () First Three Digits - Last Four Digits

Therapist Date:

Other Information:

Other First Name:

Other Last Name:

Other Phone: Area Code () First Three Digits - Last Four Digits

Other Date:

AA/NA:

No Information Available:

PHP:

PHP Facility Name:

PHP Phone: Area Code () First Three Digits - Last Four Digits

PHP Date:

IOP:

IOP Facility Name:

IOP Phone: Area Code () First Three Digits - Last Four Digits

IOP Date:

Medications Max characters: 255

Miscellaneous Information Max characters: 200

Companion Benefit Alternatives, Inc.

Form Resource Center

Discharge Form

Instructions

Patient Information

Diagnosis

Follow-up Information