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Medicaid Hospice Discharge Form Mobile App

The Medicaid Hospice Discharge Form mobile app is used when patients are being discharged from hospice services. The form includes recipient information, provider information, discharge statement and explanation. When a Medicaid recipient is discharged from a hospice program for one of the reasons listed in Medicaid Hospice Discharge Form mobile app the recipient has the right to a fair hearing regarding the decision.

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Take a peek inside the Medicaid Hospice Discharge Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    RECIPIENT INFORMATION:

  • Ico textbox

    NAME:

  • Ico textbox

    SOCIAL SECURITY NUMBER:

  • Ico textbox

    MEDICAID ID NUMBER:

  • Ico textbox

    MEDICARE NUMBER:

  • Ico statictext

    PROVIDER INFORMATION:

  • Ico textbox

    NAME OF HOSPICE:

  • Ico textbox

    NPI Number:

  • Ico textbox

    MEDICAID PROVIDER NUMBER: HSP

  • Ico textbox

    HOSPICE PHONE NUMBER:

  • Ico statictext

    SIGNATURE OF AUTHORIZED HOSPICE AGENCY REPRESENTATIVE:

  • Ico date

    Hospice benefits for the above named recipient, enrolled with this agency since

  • Ico date

    terminated

  • Ico statictext

    for the following reason: (check all that apply):

  • Ico checkbox

    Recipient is deceased.

  • Ico date

    Date of death is

  • Ico checkbox

    Prognosis is now more than six (6) months.

  • Ico checkbox

    Recipient moved out of state / service area.

  • Ico checkbox

    Safety of recipient or hospice staff is compromised.

  • Ico checkbox

    Recipient is non-compliant.

  • Ico multiline

    EXPLANATION:

  • Ico statictext

    When a Medicaid recipient is discharged from a hospice program for one of the reasons listed abov...

  • Ico signature

    SIGNATURE OF AUTHORIZED HOSPICE AGENCY REPRESENTATIVE:

  • Ico signature

    SIGNATURE OF RECIPIENT OR RECIPIENT REPRESENTATIVE

  • Ico date

    Date

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