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Run: Hospice Election and Revocation Statement Processing Form

Track hospice election and revocation details in one compliant intake form, with patient, representative, and signature fields organized for clear Medicare p...

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Submission Type

Submission Type (required)

Effective Date (required)

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 (required)

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? (required)

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. (required)

This acknowledgment confirms the election of hospice services and understanding that hospice coverage is limited to hospice-related care under the applicable Medicare benefit.

Yes No N/A

Primary Hospice Provider (required)

Attending Physician Name

Optional unless required for your internal workflow.

Scope of Benefit Acknowledgment (required)

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. (required)

Yes No N/A

Reason for Revocation

Additional Comments

Provide only information necessary for processing and audit trail purposes.

Consent, Disclosure, and Signature

Consent to Process Personal Information (required)

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.

Yes No N/A

I acknowledge that the information provided will be used only for hospice benefit processing and related compliance purposes. (required)

Yes No N/A

Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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