Hospice Election and Coordination Form

Coordination form between a facility and hospice agency to document hospice election details, attending physician information, plan of care, and visit schedule while minimizing unnecessary PHI.

Resident and Facility Information

• Resident Identifier
  Use the facility MRN, chart number, or other internal identifier. Avoid collecting SSN or full DOB unless required by policy.
• Facility Name
• Unit / Room
• Facility Contact Name
• Facility Contact Phone
• Facility Contact Email

Hospice Election Details

• Hospice Agency Name
• Hospice Election Date
  Date the resident elected hospice services.
• Election Confirmed by Agency
  Confirm that the hospice agency has acknowledged the election and is coordinating services.
• Attending Physician Name
  Enter the attending physician if known and relevant to coordination.
• Attending Physician Phone
• Services to Coordinate

Plan of Care and Clinical Coordination

• Plan of Care Received
  Check when the hospice plan of care has been received or shared with the facility.
• Primary Symptom Focus
• Special Instructions
  Include only instructions needed for safe coordination and continuity of care.
• Medication Coordination Needed
• Medication Notes
• DME / Supply Needs

Visit Schedule and Service Start

• Planned Service Start Date
• Initial Nurse Visit Date and Time
• Planned Visit Frequency
• Visit Schedule Notes
  Include preferred visit windows, after-hours instructions, or coordination constraints.

Consent, Disclosure, and Submission

• Minimum Necessary Acknowledgment
  I confirm this form includes only the minimum necessary information needed for hospice election and care coordination.
• Consent to Share Information
  I confirm that the resident or authorized representative has consented to share relevant information with the hospice agency as needed for coordination.
• Submitted By
• Submission Date