Patient Discharge Form (For Office Use Only) Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Last Name *(Copy/paste or type the patient's last name)Patient First Name *(Copy/paste or type the patient's last name)Patient Type *Select OneFMP DisabledSNPH Member (Veteran)SNPH Member (Veteran Spouse)SNPH Member (Veteran Child)Other (Cash Payment Only)Patient Issue Priority Level *Select OneStandardMedium (mild pain or discomfort)High (urgent care; chronic pain)EmergencyPatient Gender *Select OneMaleFemaleOtherDate of Birth *(MM/DD/YYYY)Patient Location *Select OnePohnpeiKosraeChuukYapPalauMarshall IslandsOther Country Outside of the U.S. & PhilippinesVHIC or DOD ID No. (if applicable)FMP Approval *Select OneYesNoPendingNOTE: New FMP patients must include VA-FMP registration form with initial claim submission. VHA Disability Rating (if applicable) *Select One10-19%20-39%40-59%50-69&70-99%100%Unknown/Not ApplicablePatient Contact Phone *Patient Contact Email *Patient's Height *(e.g., 5-10, 6-1)Patient's Weight (lbs.) *Type of Appointment *Select OneFirst Contact (Primary Care Physician)Follow-up (Primary Care Physician)Medical/Dental Referral (Primary Care Physician)Mental Health (Primary Care Physician)New Prescription (Primary Care Physician)Prescription Refill (Primary Care Physician)Other (Primary Care Physician)Other (Specialty Physician)Primary Medical Issues *Back/Shoulder/Arm (physical injury)Head/Neck (physical injury)Leg/Foot/Knee (physical injury)Other Bodily InjuryInternal Bodily Disease or CancerMental health issue(s) (e.g., PTSD/Anxiety)Vision & eye issue(s)Dental & throat issue(s)Fever, flu, or other illnessDiabetesOther (please specify in "Additional Notes" below)(select all that apply)Follow-up Visit Required *Select OneYesNoPatient Discharged By (Last Name): *c/o Medical Director, declare the foregoing to be factual and true.Additional Notes: *Submit
