Clear Form
Hospital Admission/Discharge Form
Fax completed form to (952) 853-8705
Sender/Caller Information: □ Patient
□ Hospital □ Provider
Name: _____________________________ Phone: (______)______________ Fax: (______)______________
Does the patient have other insurance? □ No □ Yes: ______________________________________
Today’s Date: _____/_____/_______ Time: _____:_____ _____
Patient Information:
Patient: _______________________________
Last
_______________________________
First
HealthPartners Member ID # : __________________ Date of Birth: ____/____/______
Admission Information:
Admission Date: _____/_____/_______
Discharge Date: _____/_____/_______
Disposition: □ Home
□ Expired
Admission Source:
□ ER/ED □ Direct
□ Scheduled
□ Nursing Home Transfer
□ Male □ Female
□ Other Hospital Transfer
□ Direct Transferred From: _____________________________
Admission Type, Bed, Unit (mark all that applies): □ Other ________________________________________
□ Med/Surg
□ Pediatric
□ ICU/CCU
□ Swing Bed
□ Mental Health
□ CH □ Detox
□ Maternity Delivery/DOB: _____/_____/_____
□ Twins □ Triplets
Baby: □Boy □Girl Name: Last________________
Baby: □Boy □Girl Name: Last________________
Baby: □Boy □Girl Name: Last________________
□ Long Term Acute Care
□ Inpatient Acute Rehab
Nursery: □ Normal
□ Level II □ Level III NICU
First______________
First______________
First______________
Hospital MRN: ___________
Hospital MRN: ___________
Hospital MRN: ___________
ICD-10 Diagnosis Code: ___________________________________________________________________
ICD-10 Procedure Code (Inpatient): __________________________________________________________
Provider Information:
Facility: ______________________________________________ Phone: (______)___________________
Street: _____________________________________________ UR Dept: (______)___________________
City: _____________________________________ State: ___________ Zip: ___________________
Facility Tax ID: ________________________________ Provider Contact Name: _________________
Attending Physician: _______________________________ _______________________________
Last
First
Phone: (______)___________________ Fax: (______)_____________________
Street: _______________________________________________________________________________
City: _____________________________________ State: ___________ Zip: ___________________
Physician Federal Tax ID: ________________________ or NPI #: ______________________________
Please include admission H&P information along with this form.
Updated 1/9/20