Discharge Notification Form

The Discharge Notification Form is issued by [Company] to the recipient and the recipient’s caregiver or legal representative whenever behavior analysis services are discharged or transferred. It documents who is being discharged, the effective date, and the reason for discharge.

The Discharge Notification Form on the right captures the recipient and caregiver names, the effective discharge or transition date, and the reason for the change. Reasons include a parent, caregiver, or recipient request, including a request made without explanation; treatment goals substantially met, or maximum benefit or a plateau reached with no further progress anticipated; a parent request despite partially achieved goals where the treatment team recommended continuation of services; ABA services no longer medically necessary, or medical issues that make continued intervention inappropriate; transfer to another provider; funding or insurance changes; payer denial of continued authorization; inability to establish contact after reasonable attempts; attendance concerns or scheduling and logistical barriers impacting continuity of care; caregiver non-participation as specified in the consent agreement; safety or environmental concerns; relocation outside the service area; or other. Additional comments and recommendations may be added.

[Company] may assist with coordination of care, transfer of records, and communication with other providers when authorized by the caregiver or legal representative and when appropriate. Questions about the notification are directed to the named Agency representative. The signed notification is filed in the recipient’s clinical record and a copy is provided to the caregiver or representative.