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Run: Hospice Election and Coordination Form

Hospice Election and Coordination Form template for documenting election details, plan of care, visit schedule, and minimum-necessary information sharing bet...

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Resident and Facility Information

Resident Identifier (required)

Use the facility MRN, chart number, or other internal identifier. Avoid collecting SSN or full DOB unless required by policy.

Facility Name (required)

Unit / Room

Facility Contact Name (required)

Facility Contact Phone (required)

Facility Contact Email

Hospice Election Details

Hospice Agency Name (required)

Hospice Election Date (required)

Date the resident elected hospice services.

Election Confirmed by Agency (required)

Confirm that the hospice agency has acknowledged the election and is coordinating services.

Yes No N/A

Attending Physician Name

Enter the attending physician if known and relevant to coordination.

Attending Physician Phone

Services to Coordinate (required)

Plan of Care and Clinical Coordination

Plan of Care Received (required)

Check when the hospice plan of care has been received or shared with the facility.

Yes No N/A

Primary Symptom Focus

Special Instructions

Include only instructions needed for safe coordination and continuity of care.

Medication Coordination Needed (required)

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 (required)

I confirm this form includes only the minimum necessary information needed for hospice election and care coordination.

Yes No N/A

Consent to Share Information (required)

I confirm that the resident or authorized representative has consented to share relevant information with the hospice agency as needed for coordination.

Yes No N/A

Submitted By (required)

Submission Date (required)

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Email (required)

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