Fillable Hospice Discharge/Hospice Revocation Form (Mississippi)

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Hospice Discharge/Hospice Revocation Form (Mississippi)

On average this form takes 11 minutes to complete

The Hospice Discharge/Hospice Revocation Form (Mississippi) form is 1 page long and contains:

  • 2 signatures
  • 10 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

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Hospice Discharge/Hospice Revocation Form
Revised 03/01/2021 DOM-1166 A
Beneficiary Information
Name:
Date of Birth:
Address:
Medicaid ID Number:
Medicare Number:
Contact Number:
Social Security Number:
Name of Guardian/Legal Representative:
Relationship:
Name of Beneficiary's Attending Physician:
Attending Physician Contact Number:
Hospice Provider Information
Name:
Medicaid Provider Number:
Address:
NPI Number:
Contact Number:
Reason: Complete Box 1 or Box 2
Beneficiary Revocation Statement:
a) 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,
b) I understand that by signing this revocation statement I will, if eligible, resume Medicaid coverage of benefits waived when the
hospice care was elected,
c) I will forfeit all hospice coverage for days remaining in this benefit period,
d) I may at any time elect to receive hospice coverage for any other hospice benefit period for which I am eligible.
________________________
Date
________________________
_________________________________________________________________________________________
Signature of Beneficiary or Guardian/Legal Representative
_________________________________________________________________________________________
Signature of Hospice Staff
Date
Hospice Discharge
The above named beneficiary was admitted to hospice on ____/____/_____ and discharged on ___/___ /_____ for the following reason:
Beneficiary deceased on _____/_____/_______.
The beneficiary is no longer eligible for Medicaid.
Beneficiary’s condition has improved and is no longer certified as terminally ill.
Beneficiary moved out of state/service area.
Safety of beneficiary or hospice staff is compromised. (Explanation must appear below)
Beneficiary is non-compliant. (Explanation must appear below and documentation efforts to counsel the recipient
must be attached).
The beneficiary has transferred to another hospice provider. (Complete the transfer form)
Explanation:__________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Box 2
Box 1
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Hospice DischargeHospice Revocation Form (Mississippi)

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Completed 6 October 2021

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