Open Door Individual Discharge Summary
Individual Name
First Name
Last Name
Type of Service being terminated/discharged:
Residential
Day Services/Employment
Transportation
Other
Location where services received (for discharge)
Park West ICF
Johnstown ICF
SCL
Open Door
CAC
NMT
UCO
Effective Date of Discharge
*
-
Month
-
Day
Year
Date
Exact Time of Discharge:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Reason for Discharge
Notification Date: Social Security Administration
-
Month
-
Day
Year
Date
Notification Date: JFS
-
Month
-
Day
Year
Date
Notification of Payee
-
Month
-
Day
Year
Date
Disconnection/transfer Phone
-
Month
-
Day
Year
Date
Disconnection/transfer Electric
-
Month
-
Day
Year
Date
Disconnection/transfer Gas
-
Month
-
Day
Year
Date
Disconnection/transfer Cable/Internet
-
Month
-
Day
Year
Date
Notification of Pharmacy
-
Month
-
Day
Year
Date
Notification of Nursing (HSC, Home Health, agency, etc.)
-
Month
-
Day
Year
Date
Notification of County Board SSA/ team
-
Month
-
Day
Year
Date
Notification of Residential Provider (Day Service/NMT only)
-
Month
-
Day
Year
Date
Transfer Meeting Date (with team/county/new provider) if applicable
-
Month
-
Day
Year
Date
New Provider:
New Provider-Contact Name:
First Name
Last Name
New Provider Contact email:
example@example.com
New Provider Phone Number Contact
-
Area Code
Phone Number
Exit Summary Report:
Suggestions for referral for continuity of care/ other follow-up:
Person Completing Form:
First Name
Last Name
Email of person completing form:
example@example.com
Date Form Completed:
-
Month
-
Day
Year
Date
Submit
Should be Empty: