Hospital discharge papers: what you are signing

Short answer

Hospital discharge papers include: the Important Message from Medicare (Form CMS-10065) explaining appeal rights; the Detailed Notice of Discharge (Form CMS-10066) if an appeal has been requested; the discharge instructions and prescription list; the discharge summary going to the next provider; and, occasionally, an AMA (Against Medical Advice) form. Signing generally acknowledges receipt, not agreement. Do not sign anything you have not read. Do request a copy of the discharge summary.

The documents you can expect

Hospital discharge is a paperwork moment, and the documents arrive in a predictable order.

1. The Important Message from Medicare (Form CMS-10065). Sometimes called “the IM.” This is the notice that tells the patient they have the right to appeal a discharge they consider premature. Federal rule requires the hospital to deliver it within two calendar days of admission and to re-deliver a signed copy no more than two calendar days before the planned discharge. Signing it acknowledges the patient received the notice — it does not waive appeal rights.

2. The Detailed Notice of Discharge (Form CMS-10066). Issued only if the patient requests a BFCC-QIO expedited review of the discharge. It explains why the hospital believes the patient no longer needs inpatient care. If the patient appeals, the hospital delivers this notice within a defined window.

3. Discharge instructions. The patient-facing summary of what to do at home: medications, activity restrictions, wound care, warning signs, follow-up appointment schedule. A nurse or discharge coordinator usually reviews these at the bedside. This is the document that answers most family questions.

4. Prescription list and pharmacy paperwork. New prescriptions, changes to existing ones, and any prior-authorization forms the outpatient pharmacy will need. Take these before leaving the floor; getting them re-issued after discharge is difficult.

5. Follow-up appointment referrals. Cards or printouts with the primary care follow-up, specialty follow-up, home health referral, and any diagnostic imaging or lab work that needs to happen post-discharge.

6. Discharge summary. The clinical record. This is the document that goes to the primary care physician and any post-acute provider (skilled nursing facility, home health agency, rehab hospital). It is the single most important document for continuity of care and is discussed at length below.

7. Occasionally: an AMA form. Only if the patient is leaving against medical advice. This is covered separately below.

What Medicare requires the hospital to do

Two federal rules govern hospital discharge for Medicare beneficiaries.

The Conditions of Participation for Discharge Planning (42 CFR 482.43). Any hospital participating in Medicare must have an “effective discharge planning process that focuses on the patient’s goals and treatment preferences.” Concretely, the regulation requires the hospital to:

• Identify patients likely to need discharge planning “at an early stage of hospitalization” — not on the day of discharge.
• Include the patient and caregivers “as active partners in the discharge planning.”
• Transfer or refer the patient “along with all necessary medical information pertaining to the patient’s current course of illness.”
• Refer to the appropriate post-acute providers where applicable.
• Inform the patient of “their freedom to choose among participating Medicare providers and suppliers.”

That last point matters. A hospital does not get to send your loved one to a specific skilled nursing facility, home health agency, or hospice without telling them their options.

The Important Message from Medicare. The CMS Hospital Discharge Appeal Notices page states that “the IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights.” The current form is CMS-10065; the companion Detailed Notice of Discharge is CMS-10066.

The discharge summary — what to ask for

The discharge summary is the clinical record that follows the patient out the door. It typically contains:

• The reason for admission and the principal diagnosis.
• A brief hospital course — what happened during the stay.
• The condition of the patient at discharge.
• Discharge medications (with changes highlighted, ideally).
• Follow-up recommendations and appointments.
• Any pending test results at discharge.

The discharge summary is used by the primary care physician to know what happened, by any post-acute provider to continue care, and by insurance to adjudicate the stay. Missing or incomplete discharge summaries are a common cause of readmission — the next provider does not know what the last provider was thinking.

Two things to ask for before leaving:

1. A copy of the discharge summary for the patient’s records. The patient has the right to their medical record. The nurse or case manager can print a copy. If they say it is not ready, note the fact and follow up in the days after discharge — most hospitals complete the summary within 24 to 48 hours.
2. Confirmation that the summary has been sent to the primary care physician. “Sent” means the summary is in the PCP’s inbox in the electronic medical record or has been faxed. Ask specifically.

The appeal right — how to challenge a discharge

If your loved one (or you, as their representative) believes the discharge is being pushed too early — that they are not medically ready to leave — the appeal path is real and works.

Concretely:

1. On the day of the planned discharge, contact the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization) named on the Important Message. The phone number is on the notice.
2. The deadline is midnight of the planned discharge day. Per the CMS-referenced IM instructions, “You must contact the BFCC-QIO and request an expedited review by midnight on the day of your planned discharge.”
3. Medicare coverage stays intact during the review. “As long as you meet that deadline, you stay in the hospital with Medicare coverage intact while the review takes place.”
4. The BFCC-QIO decides within one calendar day after receiving the pertinent information from the hospital. “The BFCC-QIO independently reviews your medical records and the hospital’s reasoning. It must issue a decision within one calendar day after receiving all the pertinent information it requested.”

Two things to know:

• The appeal is about medical necessity of continued inpatient care, not about disagreement with the discharge destination. If the disagreement is “we want SNF, hospital says home,” that is a different conversation with the case manager.
• The appeal request can be verbal to the QIO by phone. It does not require a written filing.

What if the discharge feels unsafe

Sometimes the concern is not that discharge is happening at all, but that the plan itself is unsafe — no home care set up, an unrealistic medication regimen, a house that is not accessible for the patient’s current condition. That is a different conversation than a formal discharge appeal.

The Conditions of Participation give the patient and family the right to be “active partners” in the discharge plan. Concretely: the case manager or discharge planner is the person to talk to. Named concerns get documented. If the plan does not resolve, the QIO is the escalation path.

Baba has a companion article on this specific situation — the unsafe hospital discharge piece walks through the specific case of a discharge plan that puts the patient at risk of readmission, functional decline, or worse.

Can you refuse to be discharged? The AMA question

This is one of the most-asked questions in hospital settings, and the answer is more nuanced than the paperwork suggests.

Can I discharge myself from the hospital? Yes. A competent adult patient has the right to leave the hospital at any time, for any reason or no reason at all. The hospital cannot detain a competent patient against their will.

What is an AMA discharge? “Against Medical Advice” is the label the hospital applies when a patient leaves before the clinical team believes they are ready. The hospital typically asks the patient to sign an AMA form documenting that the patient understands the recommendation to stay and is leaving anyway. Signing the form is a documentation step; it does not create a new legal or financial obligation.

Does leaving AMA void my Medicare or insurance coverage? No. This is a common myth. The American Medical Association’s guidance on Medicare and AMA discharges is direct: “Medicare generally covers hospital services rendered to patients who later leave the facility against medical advice.” The article further states that “there is no evidence that any payer, including Medicare, denies coverage solely because a patient leaves against medical advice.” The AMA cites a 2012 Journal of General Internal Medicine study titled “Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?” — the peer-reviewed evidence supports the position that this fear is a myth.

Medicare payment for the inpatient stay depends on medical necessity and the two-midnight rule, not on how the discharge is labeled. “Even if an unexpected event…causes a stay to be shorter than anticipated, the inpatient stay is still payable.”

Can family refuse discharge for a parent? Not directly. A competent adult patient’s decisions are their own. Family can advocate — asking for a case management meeting, requesting a QIO review, raising concerns through the ethics committee — but cannot override a competent patient’s choice to leave.

If the patient is not competent to make the decision (advanced dementia, altered mental status, sedation), the healthcare proxy or power-of-attorney holder makes the decision under the same authority the patient would have. The AMA framework changes accordingly — the proxy signs, and the decision is legally the patient’s.

Right to refuse discharge. In the specific case of a Medicare inpatient who believes the hospital is discharging too early, the BFCC-QIO expedited review described above is the mechanism to refuse discharge and keep coverage during the review. Outside that context, refusing to leave is generally not enforceable — but a case management meeting or an ethics consult is usually available and often resolves the underlying concern.

When the hospital refuses to discharge you. Occasionally the opposite happens. The patient is medically ready to leave, but a placement is not lined up (SNF bed not available, home health delayed, family unable to arrange transportation). Hospitals sometimes hold patients for placement issues that are not the patient’s fault. In these cases, the patient can request a case management meeting or, in extreme cases, raise the concern to hospital administration or an ombudsman.

What signing (or not signing) actually means

For most discharge paperwork, signing acknowledges that the patient received the document. It does not usually waive rights or create new obligations. Specifically:

• Signing the Important Message from Medicare — acknowledges receipt of the notice. Does not waive appeal rights.
• Signing discharge instructions — acknowledges the patient received and reviewed them with a clinician. Does not waive rights or accept liability.
• Signing a prescription list — same. Receipt acknowledgment.
• Signing an AMA form — acknowledges the patient understands the clinical recommendation and is choosing to leave anyway. Does not create financial liability beyond what would otherwise exist.

If a document is presented that looks different — a settlement, a waiver, a liability release — read it before signing. Ask the case manager to explain. Ask for a copy for your records. If the language is unclear, ask for a hospital ombudsman or the patient advocate at the hospital (most hospitals have one). Do not sign under pressure.

When to work with a patient advocate

Three situations where an independent patient advocate is worth the call before or during discharge:

1. The discharge plan seems inadequate. No home care, unrealistic medication regimen, patient unable to safely navigate their home. An advocate can attend the discharge planning meeting and press for specific commitments — home health referral, DME delivery date, follow-up appointment scheduled before the patient leaves.
2. A previous discharge went badly. If the last discharge led to readmission within 30 days or a fall at home, the risk pattern is documented and worth naming to the current discharge planner. An advocate carries the history.
3. The family is remote. A local advocate can be physically present at the discharge, verify the discharge summary, take the medications home, and confirm follow-up. This is the situation where Baba’s model — an independent advocate handling the hospital-to-home transition — most often justifies itself.

Contact us if a hospital discharge is coming up and the plan does not look right, or if a recent discharge did not go well.

Frequently asked questions

Do I have to sign the discharge papers? No. A competent patient can refuse to sign. Signing typically acknowledges receipt, not agreement. Not signing does not prevent discharge but does prevent the hospital from documenting your acknowledgment.

Will my loved one be billed if they leave against medical advice? Medicare’s position, per the American Medical Association’s guidance: “there is no evidence that any payer, including Medicare, denies coverage solely because a patient leaves against medical advice.” The inpatient stay is still payable based on medical necessity.

How much time do I have to appeal a discharge? Under the Important Message from Medicare framework: contact the BFCC-QIO by midnight of the planned discharge day. The QIO issues a decision within one calendar day of receiving the hospital’s information.

What is the difference between the discharge summary and discharge instructions? Discharge instructions are for the patient — what to do at home. The discharge summary is the clinical record for the next provider. Ask for both.

Can family override an AMA discharge? Not for a competent patient. For a patient who lacks capacity, the healthcare proxy or power-of-attorney holder speaks with the patient’s authority.

What if the discharge summary has errors? Contact the hospital medical records department or the discharging physician. Under HIPAA, the patient can request an amendment to their medical record.

How is the discharge summary different from the “discharge notice”? The Discharge Summary is the clinical narrative for continuity of care. The Detailed Notice of Discharge (CMS-10066) is a specific Medicare form issued only when a patient has appealed a discharge — it explains why the hospital believes inpatient care is no longer needed.

Does the hospital have to schedule follow-up appointments before discharge? Under 42 CFR 482.43, the discharge planning process must include “necessary medical information” and referral to post-acute providers. Specific follow-up appointment scheduling is standard practice at most hospitals but is not federally mandated as a discrete requirement.

About Baba Care. Baba Care is a patient advocacy service supporting families through hospital transitions and complex care decisions. We are not affiliated with any hospital, insurer, or the Centers for Medicare & Medicaid Services.

Medical / financial disclaimer. This article is educational and does not constitute medical, financial, or legal advice. For personal circumstances, consult a licensed clinician or attorney.

Additional source references

• Alfandre D. · Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend? · Journal of General Internal Medicine · 2012