Discharge For MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
* = Required Field
Member Information
(12345678A or 12345678T)
Facility/Agency Information

(xxx-xxx-xxxx)
(xxx-xxx-xxxx)
Discharge Information
* Date needs to be MM/DD/YYYY and must be today or earlier *
Submission Authorization:
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