N.Y. Comp. Codes R. & Regs. tit. 10 § 405.9
You have the following rights under the New York State law:
Before you are discharged, you must receive a written Discharge Plan. You or your representative have the right to be involved in your discharge planning.
Your written Discharge Plan must describe the arrangements for any future health care that you may need after discharge. You may not be discharged until the services required in your written Discharge Plan are secured or determined to be reasonably available.
If you do not agree with the Discharge Plan or believe the services are not reasonably available, you may call the New York State Health Department to investigate your complaint and the safety of your discharge. The hospital must provide you with the Health Department's telephone number if you ask for it.
For important information about your rights as a Medicare patient, see the "IMPORTANT MESSAGE FROM MEDICARE," which you must receive when admitted to a hospital.
An Important Message Regarding Your Rights as a Hospital Inpatient
Your Rights While a Hospital Patient
You have the right to receive all of the hospital care that you need for the treatment of your illness or injury. Your discharge date is determined only by YOUR health care needs, not by your DRG category or your insurance.
You have the right to be fully informed about decisions affecting your care and your insurance coverage. ASK QUESTIONS. You have the right to designate a representative to act on your behalf.
You have the right to know about your medical condition. Talk to your doctor about your condition and your health care needs. If you have questions or concerns about hospital services, your discharge date or your discharge plan, consult your doctor or a hospital representative (such as the nurse, social worker, or discharge planner).
Before you are discharged you must receive a written DISCHARGE NOTICE and a written DISCHARGE PLAN. You and/or your representative have the right to be involved in your discharge planning.
You have the right to appeal the written discharge plan or notice you receive from the hospital.
IF YOU THINK YOU ARE BEING ASKED TO LEAVE THE HOSPITAL TOO SOON
Be sure you have received the written notice of discharge that the hospital must give you. You need this discharge notice in order to appeal.
This notice will say who to call and how to appeal. To avoid extra charges you must call to appeal by 12 noon of the day after you receive the notice. If you miss this time you may still appeal. However, you may have to pay for your continued stay in the hospital, if you lose your appeal.
DISCHARGE PLANS
In addition to the right to appeal, you have the right to:
Receive a written discharge plan that describes the arrangements for any future health care you may need after discharge. You may not be discharged until the services required in your written discharge plan are secured or determined by the hospital to be reasonably available. You also have the right to appeal this discharge plan.
PATIENTS' RIGHTS
A general statement of your additional rights as a patient must be provided to you at this time.
FOR ASSISTANCE/HELP
The Independent Professional Review Agent (IPRA) for your area and your insurance coverage is:
(Hospitals are permitted to use a checklist to indicate the IPRA that the patient should contact.)
The hospital shall provide for the maintenance of evidence of sexual offenses. The hospital shall establish and implement written policies and procedures that are consistent with the requirements of this section and that shall apply to all service units of the hospital which treat victims of sexual offenses, including but not limited to medicine, surgery, emergency, pediatric and outpatient services.
The hospital shall provide for the identification, assessment, and appropriate treatment or referral of individuals who are suspected to be human trafficking victims, as that term is defined in section 483-aa of the Social Services Law and used in article 10-D of the Social Services Law. The hospital shall establish and implement written policies and procedures, which shall apply to all service unites of the hospital and, at a minimum, shall meet the following requirements:
The commissioner may withdraw approval of an independent professional review agent where such review agent fails to continue to meet approval criteria established pursuant to this subparagraph.
DISCHARGE NOTICE
DATE:/___/___
READ THIS LETTER CAREFULLY-IT CONCERNS YOUR PRIVATE INSURANCE
BENEFITS OR MEDICAID BENEFITS OR IF YOU ARE UNINSURED
PATIENT NAME: __________ PRIMARY PAYOR
____________________________________________
AT DISCHARGE:
____________________________________________
ATT. PHYS. : ______ MR NO.: ____________________________________________
ADM DATE: ___ / ___ / ___ ____________________________________________
Dear Patient:
Your doctor and the hospital have determined that you no longer require care in the hospital and will be ready for discharge on:
Day of Week __ / Date / __ ____________________________________________
IF YOU AGREE with this decision, you will be discharged. Be sure you have already received your written discharge plan which describes the arrangements for any future health care you may need.
IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge plan will not meet your health care needs, you or your representative may request a review. Contact the review agent indicated on the reverse side of this letter if you would like a review of the discharge decision.
IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of
____________________________________________
(Day and Date)
call the telephone number checked off on the reverse side of this page.
IF YOU CANNOT REQUEST THE REVIEW YOURSELF, and you do not have a family member or friend to help you, you may ask the hospital representative at extension, who will request the review for you. ____________________________________________
IF YOU REQUEST A REVIEW, the following will happen:
IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION, you will be financially responsible for your continued stay after noon of the day after you or your representative has been notified of the review agent's decision.
IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO BE IN THE HOSPITAL: for Medicaid patients, Medicaid benefits will continue to cover your stay; for private health insurance patients, coverage for your continued stay is limited to the scope of your private health insurance policy.
NOTE: If you miss the noon deadline mentioned on the first page of this notice, you may still request a review. However, if the review agent disagrees with you, you will be financially responsible for the days of care beginning with the proposed discharge date.
If you would like a review of your hospital stay after you have been discharged, you may request a review by the review agent within 30 days of the receipt of this notice or seven days after receipt of a complete bill from the hospital, whichever is later, by writing to the review agent.
I have received this notice on behalf of myself as the patient or as the representative of the patient:
Signature __ / Date / __ Time ____________________________________________ Relationship
DISCHARGE NOTICE
DATE /__/__
READ THIS LETTER CAREFULLY-IT CONCERNS YOUR PRIVATE INSURANCE
BENEFITS OR MEDICAID BENEFITS OR IF YOU ARE UNINSURED
PATIENT NAME: __________ PRIMARY PAYOR
____________________________________________
AT DISCHARGE:
____________________________________________
ATT. PHYS. : ______ MR NO.: ____________________________________________
ADM DATE: ___ / ___ / ___ ____________________________________________
Dear Patient:
Your doctor and the hospital have determined that you no longer require care in the hospital and will be ready for discharge on:
Day of Week __ / Date / __ ____________________________________________
IF YOU AGREE with this decision, you will be discharged. Be sure you have already received your written discharge plan which describes the arrangements for any health care you may need when you leave the hospital.
IF YOU DO NOT AGREE and think you are not medically ready for discharge or feel that your discharge plan will not meet your health care needs, you or your representative may request a review of the discharge decision by contacting your review agent indicated on the reverse side of this page.
IMPORTANT NOTICE ABOUT THE PAYMENT FOR YOUR CARE
* If your hospital care is covered by private health insurance, you may be charged directly while you remain in the hospital while the discharge review is being conducted. Whether you have to pay during this period will depend on your private health insurance benefits and if the review agent agrees with you that you need to stay in the hospital.
* If your hospital care is covered under the Medicaid program, Medicaid will pay for the days you remain in the hospital while the discharge review is being conducted.
IF YOU WOULD LIKE A REVIEW, you should immediately, but not later than noon of
____________________________________________
(Day and Date)
call the telephone number checked off on the reverse side of this page.
IF YOU CANNOT REQUEST THE REVIEW YOURSELF, and you do not have a family member or friend to help you, you may ask the hospital representative at extension, who will request the review for you. ____________________________________________
IF YOU REQUEST A REVIEW, the following will happen:
IF THE REVIEW AGENT AGREES WITH THE DISCHARGE DECISION, you will be financially responsible for your continued stay after noon of the day you or your representative has been notified of the review agent's decision.
IF THE REVIEW AGENT AGREES THAT YOU STILL NEED TO BE IN THE HOSPITAL: for Medicaid patients, Medicaid benefits will continue to cover your stay; for private health insurance patients, coverage for your continued stay is limited to the scope of your private health insurance policy.
NOTE: If you miss the noon deadline mentioned on the first page of this notice, you may still request a review. However, if the review agent disagrees with you, you will be financially responsible for the days of care beginning with the proposed discharge date.
If you would like a review of your hospital stay after you have been discharged, you may request a review by the review agent within 30 days of the receipt of this notice or seven days after receipt of a complete bill from the hospital, whichever is later, by writing to the review agent.
I have received this notice on behalf of myself as the patient or as the representative of the patient:
Signature __ / Date / __ Time ____________________________________________ Relationship
HOSPITAL LETTERHEAD
DATE /__/__
CONTINUED STAY DISCHARGE NOTICE
(ATTENDING PHYSICIAN AGREES/REVIEW AGENT AGREES)
READ THIS LETTER CAREFULLY-IT CONCERNS YOUR INSURANCE
BENEFITS OR MEDICAID BENEFITS
PATIENT NAME:
____________________________________________
PRIMARY PAYOR:
____________________________________________
ADDRESS: ____________________________________________
ATT.
PHYS. :
____________________________________________
MR NO.:
ADM. DATE: __/__/__
Dear Patient:
After careful review of your medical record and consideration of your own views regarding medical condition, the (name of review agent) (the review agent approved by the Department of Health) has agreed with the hospital that you no longer require care in the hospital because you are ready for discharge.
IF YOU AGREE with this decision, you should discuss with your doctor the arrangements for any further health care you may need. This means if you have health insurance benefits or Medicaid benefits, these benefits will no longer pay for any additional hospital days as of:
Day of Week __ / Date / __ ____________________________________________
____________________________________________
IF YOU DO NOT AGREE THAT YOU ARE READY FOR DISCHARGE, IMMEDIATELY AFTER RECEIPT OF THIS NOTICE YOU OR YOUR REPRESENTATIVE MAY CALL THE (name of review agent) AT (phone no.) TO REQUEST AN IMMEDIATE REREVIEW OF YOUR MEDICAL RECORD.
____________________________________________
If you cannot request the reconsideration yourself and you do not have a representative to help you, you may notify the hospital representative at extension __ to request the reconsideration to you. In either case, the individual review agent approved by the Department of Health will request your name, admission date, and telephone number where you or your representative can be reached. If the individual review agent approved by the Department of Health did not ask your views before, it must do so now.
IF YOU REQUEST A REVIEW, the following will happen:
IN EITHER CASE (2 OR 3), YOU WILL NOT HAVE TO PAY FOR ANY ADDITIONAL HOSPITAL DAYS UNTIL YOU HAVE BEEN NOTIFIED OF THE REVIEW AGENT DETERMINATION.
NOTE: If you miss the noon deadline mentioned on the reverse side of this notice, you may still request a review during your hospital stay. However, if the review agent rules against you, you will be financially responsible starting on the date you receive the notice. Of course, if the review agent determination is in your favor, you are not liable for payment for the extra days.
If you would like a review of your hospital stay after you have been discharged, you may request an individual review agent review within 30 days of receipt of this notice or seven days after receipt of a complete bill from the hospital, whichever is later, by writing to the review agent.
(REVIEW AGENT NAME/ADDRESS)
____________________________________________
____________________________________________
(Hospital Representative Signature) _ (Date) _ (Time) ____________________________________________
If your hospital stay is not covered under the per case payment system, you may still request a discharge review. However, you will continue to be charged for hospital services during the review process.
IF YOU HAVE ANY DIFFICULTY UNDERSTANDING THIS NOTICE OR IF YOU NEED MORE INFORMATION, YOU MAY CALL THE REVIEW AGENT DIRECTLY
AT: (Telephone No.)
I have received this notice on behalf of myself as the patient or as a representative of the patient to whom it is addressed:
Signature __ / Date / __ Time ____________________________________________ Relationship
cc: Attending Physician_ Hospital Billing Office ____________________________________________
N.Y. Comp. Codes R. & Regs. Tit. 10 § 405.9