Form CMS-10455 Report of a Hospital Death Associated With Restraint or Seclusion

Form CMS-10455 Report of a Hospital Death Associated With Restraint or Seclusion

What Is Form CMS-10455?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form CMS-10455?
A: Form CMS-10455 is a report that is used to document a hospital death associated with restraint or seclusion.

Q: Why is this form used?
A: This form is used to report any deaths that occur as a result of restraint or seclusion in a hospital setting.

Q: Who is required to complete this form?
A: Hospitals are required to complete this form if a death occurs that is associated with restraint or seclusion.

Q: What information is included in the form?
A: The form includes details about the patient, the circumstances surrounding their death, and any measures taken to prevent similar incidents in the future.

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Form Details:

  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CMS-10455 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services.

Download Form CMS-10455 Report of a Hospital Death Associated With Restraint or Seclusion

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  • Form CMS-10455 Report of a Hospital Death Associated With Restraint or Seclusion, Page 1
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