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Fairview Home Care and Hospice Patient Name: (Last, First) Must. ID: Adm ID: Hospice Medicare Election Statement I choose (elect) Fairview Hospice to provide my hospice care. I understand that I have
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How to fill out hospice medicare election statement
How to fill out a hospice Medicare election statement:
01
Obtain the hospice Medicare election statement form. This can typically be obtained from your hospice provider or from the Centers for Medicare and Medicaid Services (CMS) website.
02
Fill in the patient's personal information. This includes their name, address, phone number, Medicare number, and date of birth.
03
Indicate the effective date of the election. This is the date when the patient chooses to begin receiving hospice care and services.
04
Select the level of care. There are four different levels of care available in hospice: routine home care, continuous home care, inpatient respite care, and general inpatient care. Choose the appropriate level based on the patient's needs.
05
Provide any additional information required. This may include the name and contact information of the hospice provider, as well as any specific instructions or preferences for the patient's care.
06
Sign and date the form. The patient or their legal representative should sign and date the form to indicate their agreement with the election of hospice care.
07
Submit the completed form. Send the filled-out hospice Medicare election statement to the appropriate Medicare contractor or hospice provider.
Who needs a hospice Medicare election statement:
01
Patients who have been diagnosed with a terminal illness and want to receive hospice care and services.
02
Individuals who are eligible for Medicare and have chosen to receive their Medicare benefits through the hospice benefit.
03
Patients who wish to access the comprehensive services provided by a hospice team, including medical, nursing, social, and emotional support.
It is recommended to consult with a healthcare professional or hospice provider for specific guidance on filling out the hospice Medicare election statement and to determine if it is the right option for the patient's needs.
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What is hospice medicare election statement?
The hospice medicare election statement is a form that allows individuals to elect to receive hospice care benefits under Medicare.
Who is required to file hospice medicare election statement?
Individuals who wish to receive hospice care benefits under Medicare are required to file the hospice medicare election statement.
How to fill out hospice medicare election statement?
The hospice medicare election statement can be filled out by providing personal information, selecting a hospice provider, and signing the form.
What is the purpose of hospice medicare election statement?
The purpose of the hospice medicare election statement is to formally elect to receive hospice care benefits under Medicare.
What information must be reported on hospice medicare election statement?
The hospice medicare election statement must include personal information, selected hospice provider, signature, and date.
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