Crosswalk

Change #

Form

Change

1

Update form so that is adheres to CMS'
current forms formatting by adding the
Department of Health and Human Services
logo, and moving the form number, OMB
number and expiration date to the right
CMS-10065 vertical margin.

2

CMS-10065

3

CMS-10065

4

CMS-10065

5

CMS-10065

6

CMS-10065

Current Location

Reason

CMS Office of Communication prefers all
forms to have a similar appearance so that
All over
the form is easily recognized as a CMS form
Previous version required the hospital to
insert the hospital name and any other
hospital information at the top of the page
but there was no indicator line identifying
what that information was. The revision has
Create space at top of form for fill areas for
the patient and hospital names identified
patient name, patient number, hospital
and located together for easy reference.
name and hospital address
Top of page 1
Under "Your Rights as a Hospital Inpatient:"
Remove bullets 2 and 5. Simplify language
revised language to use plain language and
in bullets 1, 3 and 4. Modify content to what
to focus on information most important to
the patent needs to know immediately
hospital patients when they get this notice First section on page 1
about their rights and discharge.
Changed second section heading from
Revised all bullets in this section to shorten
"Your Right to Appeal Your Hospital
each statement, write each in plain
Discharge:" to "Your Can Appeal Your
language and focus only on key issues that
Hospital Discharge:
Second section on page 1 patients need to file an appeal.
Remove third section "How to Ask For an
Remove this heading and revise some of
Appeal of your Hospital Discharge"
Thid section on page 1
this information and include it in section 2.
Rename fourth section "If You Miss The
Deadline to Request An Appeal, You May
Change heading and revise information to
Have Other Appeal Rights:" to "What
make information easy to understand about
Happens After I Appeal?"
Fourth section on page 2 what the next steps will be.