CMS-100065/10066 Important Message from Medicare

Patient name:

Patient number:

Hospital name: Hospital address:

Hospital telephone number:

Important Message from Medicare

Your Rights as a Hospital Inpatient

• You can get Medicare-covered services. This includes medically necessary hospital services. You have a right to know what services are covered.

• You can work with the hospital to prepare for your safe discharge and arrange for services you may need after you leave. You can speak with your doctor or other hospital staff if you have any concerns.

• You can report any concerns about the quality of care you get to your Quality Improvement Organization at: {insert Quality Improvement Organization’s name and toll-free number}. Quality Improvement Organizations are independent of Medicare.

You Can Appeal Your Hospital Discharge

• If you think you’re being discharged from the hospital too soon, you can appeal right away.

• To appeal, call your Quality Improvement Organization at: {insert Quality Improvement Organization’s name and toll-free number}

• You should ask for an appeal as soon as possible and before you leave the hospital. If you appeal before you leave, you’ll have coverage while you wait in the hospital for your appeal decision.

• If you decide to appeal, your Quality Improvement Organization will look at your records and give you its decision about 2 days after you ask for an appeal.

• After you leave the hospital, you can still appeal. Call your Quality Improvement Organization if you have Original Medicare. If you have a Medicare Advantage plan call your plan at {insert plan name and toll-free number}

What Happens After I Appeal?

• If you appeal, you’ll get another notice called the Detailed Notice of Discharge. It explains the reasons why your covered hospital stay shouldn’t continue.

• If your appeal decision is favorable to you, Medicare will continue to cover your hospital services.

• If you don’t appeal, or if the decision on your appeal isn’t favorable to you, you may have to pay for any services you get after your discharge date.

Additional Information (Optional):

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