Current hospital status Admitted as an inpatient Observation or outpatient status Not sure yet
Discharge timing concern Discharge is planned today Discharge may happen tomorrow or soon Already left the hospital Planning ahead before a discharge date
Important Message from Medicare status Received the Important Message from Medicare Not received or cannot find it Asked and waiting for a copy Not sure what the notice is
Detailed Notice of Discharge status Not requested yet Requested after asking for an appeal Received the Detailed Notice of Discharge Not sure
QIO contact status QIO number not found yet QIO number found, not called Called QIO or left message Not sure who to call
Primary safety concern Condition, symptoms, or recovery still feels unstable Caregiver teaching is not complete Equipment, medicines, oxygen, or supplies are not ready Home help, transportation, or follow-up is not arranged Coverage, rehab, or next placement is unclear
Discharge team response Have not asked the discharge team yet Asked and waiting for answers Some concerns have been addressed Family still disagrees with discharge timing
Caregiver available at discharge? Yes, caregiver is ready Partly ready but needs instructions or support No reliable caregiver plan yet Caregiver help not expected
Records folder status Not started Some notices or notes gathered Organized with copies and call notes Missing key notices or discharge papers
Need unbiased help? Yes, need Medicare or SHIP help Maybe, if notices are unclear Already contacted Medicare, SHIP, QIO, or advocate No, just organizing questions
Use this before leaving the hospital when discharge feels unsafe.
Do not enter Medicare numbers, Social Security numbers, birth dates, diagnoses, claim numbers, room numbers, account numbers, or private medical records into this worksheet. Keep personal details in a secure folder for Medicare, the QIO, the plan, the hospital, SHIP, or a qualified advocate.
This planner is educational and administrative only. It does not file an appeal and is not legal, medical, insurance, benefits, financial, or discharge advice. Fast-appeal rights and deadlines depend on the exact notice, coverage, hospital status, and timing.
Official references:
Medicare fast appeals ,
CMS Important Message and Detailed Notice ,
Medicare discharge planning checklist ,
Medicare inpatient or outpatient status .
