Hospice Election and Coordination Form

A coordination form between a facility and hospice agency to document hospice election details, admission coordination, and the election date while minimizing unnecessary PHI.

Resident and Facility Information

• Resident Name
• Resident Identifier
  Use your facility's internal identifier if needed. Do not enter SSN.
• Facility Name
• Unit / Room

Hospice Election Details

• Hospice Election Date
  Date the resident elected hospice services.
• Election Received By
  Name or role of the person who received the election notice.
• Election Source
• Election documentation received?

Hospice Agency Coordination

• Hospice Agency Name
• Hospice Contact Name
• Hospice Contact Phone
• Hospice Contact Email

Care Coordination and Service Start

• Coordination Status
• Planned Hospice Service Start Date
• Care Coordination Notes
  Include only information needed for care coordination. Avoid unnecessary PHI.

Consent, Disclosure, and Submission

• I confirm this form includes only the minimum necessary information for hospice coordination.
• Consent to share relevant coordination information with the hospice agency
  Use only if your workflow requires a consent acknowledgment for disclosure.
• Submitted By
• Submitted By Role