Get 2565 Facility Admission Notice

Completing the 2565 Facility Admission Notice is an essential step for ensuring proper admission of a beneficiary to a facility. This guide will provide clear, step-by-step instructions to assist you in filling out this document accurately and efficiently online.

Follow the steps to complete the Facility Admission Notice.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the format of Last, First, Middle in field 1.
3. Indicate the patient's gender by checking 'M' for male or 'F' for female in field 2.
4. Fill in the patient's birth date in field 3, using the format MM/DD/YYYY.
5. In field 4, provide the patient's Social Security number using the specified format.
6. Enter the home address of the patient, including street number, apartment number (if applicable), city, state, and zip code in fields 5, 6, 7, and 8.
7. Document the name of the person responsible for the patient in field 6, along with their relationship to the patient in field 8.
8. In field 9, fill out the phone number of the responsible person.
9. Provide details about the facility in sections 10 to 15, including the provider name, provider address, attending physician's name, facility type, and the date of admission.
10. Indicate if the admission is likely to be 30 days or longer in field 18, and estimate the total length of stay if applicable.
11. Document the patient's present status in field 19, and provide primary and secondary diagnosis in fields 20 and 21.
12. Indicate the source of the patient's admission in field 22.
13. Provide information regarding Medicare or private health insurance in fields 23 to 35, as applicable.
14. Ensure the Patient Certification section is completed and signed by the patient or their representative in fields 36 and 37.
15. Finally, review all entries for accuracy, then save your changes, download, print, or share the form as needed.

Complete the 2565 Facility Admission Notice online today to ensure a smooth admission process.