Hospice Notice of Election Form

Hospice Notice of Election Form
Patient Name
First NameLast Name
Which beneficiary do you choose the hospice benefit from Center for Hospice Care?
MedicareCommercialSelf-pay
Start of Care Date
MonthDayYear
Date
Do you have Attending Physician/Nurse Practitioner?
YesNo
Attending Physician/Nurse Practitioner Name
First NameLast Name
I acknowledge that I have been given a full explanation and that I understand the purpose of hospice care. Hospice care is to relieve pain and other symptoms associated with terminal illness and related conditions and similar conditions.The focus of Hospice care is to provide comfort and support to both me and my family/caregivers.
Beneficiary Signature
Clear
Agency Representative Signature
Clear
Is beneficiary unable to sign?
YesNo
Please explain the reason
Representative Signature
Clear
Date
MonthDayYear
Date
Should be Empty: