A non-participating hospital that admits a Medicare patient in an emergency uses this statement to support payment for the emergency inpatient or outpatient services. It gives the reviewing physician the facts: when the emergency occurred, where the patient was first seen, admitting signs and symptoms, emergency services provided, why the patient remained an emergency case, and the earliest date transfer or discharge was medically permissible.
The hospital enters the patient's name and claim number in Section A. The attending physician completes Section B, items 1 to 11, and signs with M.D. or D.O. credentials, the date and contact details.
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Attending Physician's Statement and Documentation of Medicare Emergency
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Yes. The form says a copy of the patient's chart, including at minimum the admission history and physical, admission nursing notes, all physician orders, progress notes and the discharge summary, may be submitted in addition to or instead of the form, if it covers all the information requested.
Inpatient and outpatient hospital services necessary to prevent the death or serious impairment of the patient's health which, because of that threat, require the most accessible hospital equipped to furnish them. Item 5 asks whether special equipment or personnel at the admitting hospital was a factor.
Item 9 asks for the earliest date it was medically permissible to transfer the patient to a participating hospital or extended care facility, or to discharge them. Item 8 lists the findings, complications or special services that kept the patient an emergency case until then.