Form Cms-1771 - Attending Physicians Statement And Documentation For Medicare Emergency

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 0938-0023

ATTENDING PHYSICIAN’S STATEMENT AND DOCUMENTATION OF MEDICARE EMERGENCY

SECTION A

1. PATIENT’S NAME

2. HI CLAIM NUMBER

SECTION B

(To be completed by attending physician)

IMPORTANT: Please supply all information requested in order that the reviewing physician may promptly process the claim. A copy of the patient’s chart

including a minimum of admission history and physical, admission nurse’s notes, all physician’s orders, progress notes, and discharge summary may be

submitted in addition to or in lieu of this form if it covers all information requested below.

1. Date and approximate hour when emergency

2. When and where was the patient first seen by you or another physician in connection with the emergency PRIOR

occured which resulted in hospital admission.

TO ADMISSION TO THE HOSPITAL?

DAY

YR.

APPROXIMATE HOUR

DAY

YR.

APPROXIMATE HOUR

Home

Physician’s Office

A.M.

P.M.

A.M.

P.M.

Emergency Room

Accident Site

Other:

(Specify)

3. DATE AND HOUR OF ADMISSION

ADMITTING DIAGNOSIS(ES)

4. Emergency services are defined in the Medicare program for purposes of payment as inpatient and outpatient hospital services which are necessary to prevent the

death or serious impairment of the health of the individual and which, because of the threat to the life or health of the individual, necessitate the use of the most

accessible hospital available which is equipped to furnish such services.

In your opinion was this an emergency as defined under Medicare?

Yes

5. List special equipment or special personnel available at the admitting hospital if such special equipment or special personnel was a factor in necessitating admission

there rather than to a hospital which participates in the Medicare program.

6. Indicate specific signs and symptoms of the patient at the time of initial examination which will help to justify this case as a Medicare emergency. (If the patient was

admitted because of a change in a chronic condition or a condition which existed for several days prior to admission, please indicate the ACUTE changes )

6.a. Other findings on hospital admission

Ambulatory

Conscious

Unconscious

Non-ambulatory

Semi-conscious

Pain - Yes

Location of pain

Temperature

Blood Pressure

Pulse

/min.

Repirations

/min.

Pertinent laboratory findings at that time

7. List specific emergency services and care including surgery and other procedures (i.e., cystoscopy, bronchoscopy, X-rays, etc.) provided during the hospital admission.

EMERGENCY SERVICE

DATE(S)

RATIONALE OR REASON FOR SERVICE

(Do not list elective procedures or surgery)

Blood transfusion

Yes

FORM CMS-1771 (9-77)