Track Change - Important Message

Patient name:
Patient number:
Hospital name:
Hospital address:
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Important Message from Medicare
Patient name:

• You can getreceive Medicare- covered services. This includes medically necessary hospital services. and
services you may need after you are discharged, if ordered by your doctor. You have a right to know
about these what services are covered., who will pay for them, and where you can get them.

You can work with the hospital to prepare for your safe discharge and arrange for services you may need
after you leave. the hospital. You can speak with your doctor or hospital staff if you have any concerns.
When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your
planned discharge date.

•
•

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Patient number:

Your Rights as a Hospital Inpatient:

•

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You can be involved in any decisions about your hospital stay.

• You can report any concerns you have about the quality of care you getreceive to your Quality

Improvement OrganizationQIO at: {insert Quality Improvement OrganizationQIO’s name and toll-free
number of QIO}. Quality Improvement Organizations are independent of Medicare. The QIO is the
independent reviewer authorized by Medicare to review the decision to discharge you.

• You can work with the hospital to prepare for your safe discharge and arrange for
services you may need after you leave the hospital. When you no longer need inpatient
hospital care, your doctor or the hospital staff will inform you of your planned discharge
date.

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• You can speak with your doctor or other hospital staff if you have concerns about being
discharged.
Your CanRight to Appeal Your Hospital Discharge:
• You have the right to an immediate, independent medical review (appeal) of the decision to

discharge you from the hospital. If you do this, you will not have to pay for the services you receive
during the appeal (except for charges like copays and deductibles).If you think you’re being
discharged from the hospital too soon, you can appeal right away.

• If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer also will

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look at your medical records and/or other relevant information. You do not have to prepare anything
in writing, but you have the right to do so if you wish.To appeal, call you Quality Improvement
Organization at: {insert Quality Improvement Organization’s name and toll-free number}

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• If you choose to appeal, you and the reviewer will each receive a copy of a detailed explanation

about why your covered hospital stay should not continue. You will receive this detailed notice only
after you request an appeal.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 the QIO finds that you are not ready to be discharged from the hospital, Medicare will continue to

cover your hospital services. 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.

• If the QIO agrees services should no longer be covered after the discharge date, neither Medicare nor

• If you do not appeal, you may have to pay for any services you receive after
your discharge date.
See page 2 of this notice for more information.
How to Ask For an Appeal of your Hospital DischargeWhat Happens After I Appeal?
• You must make your request to the QIO listed above. 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.

• Your request for an appeal should be made as soon as possible, but no later than your planned

discharge date and before you leave the hospital.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.

• The QIO will notify you of its decision as soon as possible, generally no later than 1
day after it receives all necessary information.
• Call the QIO listed on Page 1 to appeal, or if you have questions.
If You Miss The Deadline to Request An Appeal, You May Have Other Appeal Rights:
• If you have Original Medicare: Call the QIO listed on Page 1.
• If you belong to a Medicare health plan: Call your plan at {insert plan name and
toll-free number of plan}

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Form CMS 10065• E x p . xx/xx/2xxxx• OMB approval 0938-1019

your Medicare health plan will pay for your hospital stay after noon of the day after the QIO notifies
you of its decision. If you stop services no later than that time, you will avoid financial liability. 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 tollfree number}

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Additional Information (Optional):

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Please sign below to indicate you received and understood this notice.

Sign below to show you received and understood this notice.

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Signature of patient or representative

Date/Time

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I have been notified of my rights as a hospital inpatient and that I may appeal my
discharge by contacting my QIO.

Signature of Patient or Representative

Date

/ Time

Form CMS 10065• E x p . xx/xx/2xxxx• OMB approval 0938-1019

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You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You also have the right to file a complaint if you feel
you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more
information. TTY users can call 1-877-486-2048.Paid for by the Department of Health & Human Services.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938- 0953. The time required to prepare and
distribute this collection is 10 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary.
If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA
Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

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Paid for by the Department of Health & Human Services.

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You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also
have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY
users can call 1-877-486-2048.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-1019. The time required to complete this information collection is estimated to average 15 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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