Hospice Election and Revocation Statement Processing Form

Processes a patient's hospice election statement and any revocation, including acknowledgment of the hospice benefit scope and related Medicare election details.

Submission Type

• Submission Type
• Effective Date
  Enter the date the election or revocation becomes effective.
• Reason for Submission
  Briefly describe the reason for this election or revocation. Do not include unnecessary medical details.

Patient Information

• Patient Full Name
• Date of Birth
  Optional unless needed to resolve a duplicate record or verify identity.
• Medicare Beneficiary Identifier (MBI)
  Collect only if needed for billing or eligibility verification.
• Patient Phone Number

Representative or Authorized Person

• Is a representative or authorized person completing this form?
• Representative Name
• Relationship to Patient
• Authority Documentation
  Upload supporting documentation only if required by your organization.

Hospice Election Details

• I acknowledge that I am electing hospice coverage and understand the scope of the hospice benefit.
  This acknowledgment confirms the election of hospice services and understanding that hospice coverage is limited to hospice-related care under the applicable Medicare benefit.
• Primary Hospice Provider
• Attending Physician Name
  Optional unless required for your internal workflow.
• Scope of Benefit Acknowledgment
• Questions or Clarifications

Hospice Revocation Details

• I understand that I am revoking my hospice election and that hospice coverage will end on the effective date entered above.
• Reason for Revocation
• Additional Comments
  Provide only information necessary for processing and audit trail purposes.

Consent, Disclosure, and Signature

• Consent to Process Personal Information
  I consent to the collection and processing of the personal information in this form for hospice election or revocation processing, recordkeeping, and audit trail purposes.
• I acknowledge that the information provided will be used only for hospice benefit processing and related compliance purposes.
• Signature
• Signature Date