Hospice Election and Coordination Form
Document hospice election details, coordinate admission with the hospice agency, and record the service start date while keeping PHI to the minimum necessary. Use it to create a clear audit trail for facility-to-hospice handoff.
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Built for: Skilled Nursing · Assisted Living · Hospice Care · Long Term Care
Overview
This Hospice Election and Coordination Form template is built to document the resident’s hospice election, capture the receiving hospice agency’s contact details, and record when services are expected to start. It gives facilities a structured way to coordinate the handoff without relying on scattered emails, phone notes, or overly broad intake forms.
Use it when a resident has elected hospice and the facility needs a clear record of the election date, who received the information, which agency is involved, and whether the coordination is pending or confirmed. The template is especially useful when multiple staff members touch the workflow and you need a consistent audit trail for internal review.
Do not use this form as a general clinical intake or a place to collect broad medical history. It is not meant to replace the hospice agency’s own admission paperwork, and it should not ask for unnecessary PHI. Keep the notes field focused on coordination details, use conditional logic only where it reduces clutter, and make consent and disclosure language explicit. If the resident has not elected hospice yet, or if the task is only to track a referral lead, a different referral or care transition form is a better fit.
Standards & compliance context
- The template supports HIPAA minimum-necessary handling by limiting the form to coordination data needed for the hospice handoff.
- The consent and disclosure section helps document that information shared with the hospice agency is intentional and role-based.
- If the form is exposed to residents, family members, or external partners, it should meet WCAG 2.1 AA accessibility expectations for labels, validation, and keyboard navigation.
- Clear required-versus-optional fields and progressive disclosure reduce unnecessary data collection and support GDPR data minimization principles where applicable.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Resident and Facility Information
This section identifies the resident and the facility location so the hospice handoff can be matched to the correct record.
- Resident Name
-
Resident Identifier
Use your facility’s internal identifier if needed. Do not enter SSN.
- Facility Name
- Unit / Room
Hospice Election Details
This section captures the election date and receipt details that establish when hospice coordination began.
-
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
This section records the hospice agency and the direct contact information needed to complete the admission handoff.
- Hospice Agency Name
- Hospice Contact Name
- Hospice Contact Phone
- Hospice Contact Email
Care Coordination and Service Start
This section tracks whether the handoff is pending or confirmed and documents when services are expected to begin.
- Coordination Status
- Planned Hospice Service Start Date
-
Care Coordination Notes
Include only information needed for care coordination. Avoid unnecessary PHI.
Consent, Disclosure, and Submission
This section confirms minimum-necessary sharing, documents consent to coordinate with hospice, and preserves who submitted the form.
- 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
How to use this template
- 1. Enter the resident and facility information exactly as needed to identify the handoff, using a resident identifier only if your workflow requires it.
- 2. Record the hospice election date, who received the election, and whether the election document was received so the timeline is clear.
- 3. Fill in the hospice agency name and the direct contact details for the person handling coordination, using the correct field type for phone and email.
- 4. Set the coordination status, add the service start date when confirmed, and keep care notes limited to the minimum necessary details for the transfer.
- 5. Review the consent and minimum-necessary acknowledgment before submission, then submit the form under the name and role of the staff member responsible for the handoff.
Best practices
- Keep the resident identifier to the minimum necessary and avoid collecting full identifiers unless your process requires them.
- Use date-picker fields for election and service start dates so the record is consistent and easy to validate.
- Make coordination status values specific, such as pending, confirmed, or completed, so staff can tell what still needs action.
- Limit care notes to handoff details and avoid turning the form into a general charting field.
- Use conditional logic to show follow-up fields only when the election document is missing or the service start date is not yet confirmed.
- Mark optional fields clearly so staff do not assume every field is required.
- Capture the submitter’s name and role to preserve accountability and support the audit trail.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use this hospice election and coordination form?
This form is typically used by skilled nursing facilities, assisted living communities, discharge planners, and hospice agency coordinators. It helps the people managing the handoff capture the election date, agency contact details, and service start information in one place. The submitter should be someone authorized to document care coordination and share only the minimum necessary information.
What is the difference between hospice election details and hospice agency coordination?
Hospice election details document the resident’s decision and the date the election was received. Hospice agency coordination captures who the hospice agency is, how to reach them, and whether service start has been confirmed. Keeping these sections separate makes the record easier to review and reduces unnecessary PHI.
How often is this form completed?
It is usually completed when hospice election is first received and updated when the hospice agency is confirmed or the service start date changes. Some facilities also reuse it during transitions, readmissions, or when a different hospice provider becomes involved. The form is not meant for daily charting.
Does this form need to collect a lot of resident health information?
No. This template is designed around data minimization and should only collect the fields needed to coordinate hospice admission and document the election. Avoid adding diagnosis details, full clinical histories, or other PHI unless they are necessary for the handoff. If a note is needed, keep it brief and specific to coordination.
What should be included in the consent and disclosure section?
The consent section should confirm that the submitter understands what information will be shared with the hospice agency and that only the minimum necessary information is being disclosed. If your workflow allows it, include an acknowledgment that the resident or authorized representative has elected hospice and that the facility may coordinate care with the agency. This section should also identify who submitted the form and in what role.
What are common mistakes when using this form?
Common mistakes include leaving the election date blank, entering free-text contact details in the wrong field type, and collecting more PHI than the coordination task requires. Another frequent issue is skipping the service start date or failing to record who received the election. The form should also avoid vague status values that do not clearly show whether coordination is pending, confirmed, or complete.
Can this form be customized for different facilities or hospice agencies?
Yes. You can adapt the resident and facility fields, adjust the coordination status options, and add conditional logic for agency-specific handoff steps. Keep required fields limited to what is truly needed for the workflow, and use progressive disclosure so optional notes or follow-up fields only appear when relevant. If your process includes an internal audit trail, keep that field visible to staff but not to external submitters.
How does this compare with handling hospice coordination by email or phone?
Email and phone calls can work for quick communication, but they often leave gaps in the record and make it harder to confirm what was shared, when it was received, and by whom. This form creates a structured record with validation, clear submission ownership, and a consistent handoff process. It is especially useful when multiple staff members need to coordinate the same resident’s transition.
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