Hospice Revocation Form

Hospice Revocation Form
Beneficiary Information
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Medicaid ID Number
Medicare Number
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Guardian/Legal Representative
First NameLast Name
Relationship
Name of Beneficiary's Attending Physician
First NameLast Name
Attending Physician's Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Hospice Provider Information
Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medicaid Provider Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Beneficiary Revocation Statement
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.
Signature of Beneficiary or Guardian/Legal Representative
Clear
Date
MonthDayYear
Date
Signature of Hospice Staff
Clear
Date
MonthDayYear
Date
Should be Empty:

Hospice Revocation Form

Beneficiary Information

Hospice Provider Information

Beneficiary Revocation Statement