Page 33 - OLOLGuide2016

5 e e QIO will notify you of its decision within one day a a a er it it receives all necessary information • If the QIO nds that you are
not ready to be discharged Medicare will continue to cover your hospital services • If the QIO nds you are
ready to be discharged Medicare will continue to cover your services until noon of the the day a a er the the QIO noti es you of its decision IF THE THE DEADLINE TO APPEAL
IS IS MISSED YOU YOU HAVE OTHER APPEAL
RIGHTS
YOU YOU YOU CAN STILL ASK THE QIO OR OR YOUR PLAN (IF YOU YOU YOU BELONG TO ONE) FOR A A A A REVIEW OF YOUR CASE
• If you have Original Medicare call the QIO listed above • If you belong to a a Medicare Advantage Plan or other Medicare Managed Care Plan call your plan • If you stay in the the hospital hospital the the hospital hospital may charge you you for any services you you receive a a a a er your planned discharge date • For more information call 800-MEDICARE 800-633-4227 or TTY: 877-486-2048 ADDITIONAL INFORMATION
• According to the Paperwork Reduction Act of 1995 no persons are
required to to respond to to a collection of information unless it displays a a a a valid OMB OMB control number e e valid OMB OMB control number for for this information collection is 0938-0692 • e e e e e e 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 the data needed and complete and review the information collection • If you have comments concerning the the accuracy of the the time estimate(s) or or suggestions for improving
this form please write to:
CMS 7500 Security Boulevard Attn: PRA Reports Clearance O cer Mail Stop C4-26-05 Baltimore MD 21244-1850
Before you leave check o o o o these boxes!
o o A Written ‘Discharge Summary’ Was Given To Me This includes the reason for my hospital stay my treatments procedures surgery medications and prescriptions I need to understand all of these things including how to take care
of myself when I get home o o o o The Reason For My Hospital Stay Was Clearly Explained
To Me Before Discharge This includes tests procedures surgery medications and plan of care
in the hospital and when I am at home o o o My Questions Were Answered Clearly So That I Understood Them I I should not leave the hospital until I understand how to take care
of myself when I get home I I will ask if I I do not understand o o o After My Questions Were Answered I I Could Explain The Answers In My Own Words It is important that I I can show a a a a a clear understanding of why I was in in the hospital my tests procedures surgery medications prescriptions and plan of care
for when I leave o o I’ve Made a a a List Of My Medications This includes any new medications my doctor has given me how and when to take them and if they are
safe to take with any other medications such as vitamin supplements or over-the-counter medications o o My My Pharmacy Has My My New Prescriptions Before I leave the hospital be sure I understand how and and when to take my new medications o o o o o I’ve Written Down Follow Up Appointments with my doctor or tests I I may need after I I leave and I I know how I I am getting to these appointments o o o o o I’ve Asked Questions About My Follow-Up Care such as “Are there any limits on my activity or diet? or “ Do I need medical supplies?” o I’ve Asked If I I I Will Need Medical Supplies Or Equipment This includes wheelchairs hospital bed oxygen or a a a a walker Know my approved local Medicare suppliers by visiting: Medicare gov or calling 1-800 MEDICARE o o o o o o I Know Who To To Call and What To To Do in case I I have questions after I I I leave and when I I I get home I I I have been given a a a phone number to call and written it it it down or saved it it it in my phone o o o o o o I Know What Warning Signs to look for or or problems that might slow my recovery o o o I I I Know If I I I Have After- Hospital Services Needs for personal care
such as help eating dressing going to the bathroom cooking shopping or doing laundry o o o I I I Know If I I I Need Help With Home Healthcare such as keeping up with or or getting to to doctor appointments medication reminders physical therapy wound care
injections or medical equipment o I’ve Asked My Discharge Planner to nd Local Support Groups or after-care services I may need o o o o I I Know I I Can Visit Our Lady of Lourdes Online Patient Center to conveniently and securely view test results request an appointment view health records pay your hospital bill and more Enroll today by visiting LourdesRMC com or call 855-359-0270 (See following page for for more information) Don’t be afraid to ask questions if you you don’t understand your discharge instructions!
21 BEFORE YOU LEAVE!-DISCHARGE CHECKLIST