1. The Medicaid Hospice Program has been explained to me. I have been given the opportunity to discuss the services, benefits requirements and limitations of this program and the terms of the revocation of these services,
2. I understand that by signing this revocation statement I will, if eligible, resume Medicaid coverage of benefits waived when the hospice care was elected,
3. I will forfeit all hospice coverage for days remaining in this benefit period,
4. I may at any time elect to receive hospice coverage for any other hospice benefit period for which I am eligible.