Medicare Hospital Stay Waiver Extension Request
Submit your request to extend a Medicare hospital stay waiver. Please complete all required fields and provide supporting documentation.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Medicare Number (do not enter SSN)
*
Patient Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital/Facility Name
*
Attending Physician Name
*
First Name
Last Name
Original Admission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Original Discharge Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Waiver Extension Request
*
Clinical Justification for Extension (summary of medical necessity)
*
Upload Supporting Documentation (e.g., medical records, progress notes)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Contact Email Address for Notifications
*
example@example.com
Signature of Requestor (Provider or Authorized Representative)
*
Submit Request
Submit Request
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