News & Publications

This is for PA HealthChoices providers only.

Directions: This form is used to communicate to Magellan when a member is being discharged from a service which has an open authorization. Please complete this form within a timely manner, preferably 3 business days, of discharge from services. Business or clinical staff may complete this form. Thorough discharge information increases Magellan’s ability to monitor continuity of care and collect member focused outcome data.

MEMBER INFORMATION

Member Name *

Medicaid Number *

Date of Birth *

Address *

Phone Number *

County *

PROVIDER INFORMATION

Provider Name *

Provider MIS# *

Provider Tax ID # *

Provider Phone *

Admin Contact Person *

Admin Contact Phone *

SERVICE INFORMATION

Authorized service and CPT Code *

Discharge Diagnosis - Use ICD-10 coding *

Discharge Date (cannot be more than 2 days into the future) *

Reason for discharge *

Services member has been referred to at Time of Discharge *

Name(s) of person or agency providing service after discharge (including address and phone) *

Have appointments with this/these providers been scheduled? *

Discharge medications (if any; include name, dose, frequency, amount supplied and recent changes)

Closure: please complete ONLY if submitting for complete member closure from all MH treatment - not for a level of care or provider change.

Member's Primary Care Physician

Has a PCP been identified for the member to be linked with upon discharge?

Has outreach to the PCP to coordinate care after discharge occurred? *

News & Publications

This is for PA HealthChoices providers only.

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