Late Notice Letter for ER Admit and Discharge

Date: ________________________________

To: _________________________________

In Care of: ____________________________

Regarding: An Important Message From Medicare About Your Rights

Medicare has instituted a practice effective 7/2/07 of informing hospital inpatients of their rights to participate in discharge planning, and the right to appeal a discharge that they feel is not appropriate. The form, "An Important Message From Medicare About Your Rights," is an acknowledgement of your understanding of these rights.

Due to your emergency admission on ____________________, and your early discharge on __________________, our office's efforts to anticipate your discharge were not successful — you left today before we were able to present this form for you to sign.

Please read and sign the enclosed form, "An Important Message From Medicare About Your Rights." Keep the bottom two copies and return the top copy to Steven's Hospital in the enclosed envelope for inclusion in your hospital chart.

If you have questions, you can call the Case Management office at 425-640-4668 during business hours. The "Important Message from Medicare" also has the Case Management phone number and a phone number at Qualis Health to appeal a discharge decision.

Thank you for your attention to this matter.

Case Management Office
Stevens Hospital
21601 76th Avenue West
Edmonds, WA 98026