Get the free Hospice Election Form 01.14

St. Luke Missionary Hospice Election of Hospice Benefit I, choose to receive hospice care from St. Luke Missionary Hospice. I have been given a full understanding of the palliative (pain and symptom

How to fill out hospice election form 0114

How to fill out hospice election form 0114:

1. Start by carefully reading the form instructions provided with hospice election form 0114. These instructions will guide you through the process, clarify any doubts, and provide important information.
2. Begin by entering the patient's name, address, and social security number in the appropriate fields on the form. Ensure that all the information is accurate and up to date.
3. Proceed with filling out the patient's Medicare number and the effective date of the election period. Be sure to double-check this information to avoid any errors.
4. Next, indicate the type of facility where the patient will receive hospice care. This could include their home, nursing home, or assisted living facility. Select the appropriate option by marking a tick or filling in the corresponding details.
5. Additionally, you may need to provide information regarding the attending physician who will oversee the patient's hospice care. Include their name, address, and contact details as requested on the form.
6. The hospice provider information is another crucial part of the form. Specify the name, address, and contact details of the hospice provider that the patient has chosen to receive care from.
7. Check any applicable boxes to indicate the hospice providers that will furnish the care. You may need to select services such as nursing care, social worker services, or spiritual counseling, depending on the patient's needs and preferences.
8. Finally, review the completed form thoroughly to ensure accuracy and completeness. Make any necessary corrections or additions before signing and dating the form.
9. Keep a copy of the filled-out hospice election form 0114 for your records and submit the original to the appropriate authority or organization as specified in the form instructions.

Who needs hospice election form 0114:

1. Patients who are eligible for hospice care under Medicare or other insurance plans may require hospice election form 0114.
2. This form is necessary for individuals who have decided to receive hospice care services from a specific hospice provider.
3. People who have determined the type of facility where they will receive hospice care, such as their home, nursing home, or assisted living facility, will need to complete and submit hospice election form 0114.
4. Patients who have chosen an attending physician to oversee their hospice care will need this form to establish the necessary arrangements.
5. Individuals who have decided which hospice services they will receive, such as nursing care, social worker services, or spiritual counseling, may be required to complete this form to ensure proper documentation and coordination of care.

For pdfFiller’s FAQs

What is hospice election form 0114?

Hospice election form 0114 is a legal document that allows a patient to elect to receive hospice care benefits under Medicare.

Who is required to file hospice election form 0114?

The patient or their authorized representative is required to file hospice election form 0114.

How to fill out hospice election form 0114?

Hospice election form 0114 can be filled out by providing the necessary personal and medical information related to the patient's hospice care election.

What is the purpose of hospice election form 0114?

The purpose of hospice election form 0114 is to formally elect to receive hospice care benefits under Medicare.

What information must be reported on hospice election form 0114?

Hospice election form 0114 requires information such as patient's name, Medicare number, date of election, and signature.

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