Patient Deactivation Request Survey

Please use this form when requesting deactivation of a patient to exclude them from consideration in the next report cycle. If you have more than 5 patients to deactivate, this form will loop back to the beginning once you hit "submit".

1.Facility Name(Required.)

2.TQIP Facility ID (5-6 digits)(Required.)

3.Who should we reach out to confirm whether the patient can be deactivated, or if we need more information?(Required.)

Name

Please fill out the following with the information of each patient you would like to deactivate. If you have less than 5 patients to deactivate, you can leave the remaining patient forms empty. Please note that we will need a detailed rationale for deactivation that explains how the patient no longer meets NTDS requirements.

Example: This patient was originally submitted with an ICD-10 code of S11.021A, but that was miscoded and the patient does not actually have any ICD-10 codes that currently meet NTDS inclusion criteria.

4.Patient #1(Required.)

Patient ID

Admission Month and Year