Get the free SE1631. Sample Hospice Election Statement - cms

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MAN Matters Number: SE1631 Revised Related Change Request (CR) #: N/A Article Release Date: December 13, 2016, Effective

How to fill out se1631 sample hospice election

How to fill out se1631 sample hospice election

1. To fill out the se1631 sample hospice election form, follow these steps:
2. Start by entering the patient's personal information in the designated fields. This includes the patient's name, Social Security number, date of birth, gender, and Medicare number.
3. Next, provide the patient's contact information, such as their address, phone number, and email (if applicable).
4. Indicate the date when the hospice election becomes effective.
5. Specify the level of care the patient has chosen by selecting the appropriate option (Routine Home Care, Continuous Home Care, Inpatient Respite Care, or General Inpatient Care).
6. If the patient elected to receive hospice care in place of Medicare-covered benefits for the terminal illness, check the corresponding box.
7. Provide information about the attending physician, including their name, address, and NPI (National Provider Identifier) number.
8. If there is a different physician providing the hospice care, enter their details as well.
9. Indicate the patient's choice for the attending physician's specialty, if applicable.
10. Sign and date the form, confirming that the information provided is accurate to the best of your knowledge.
11. Additionally, have the patient or authorized representative sign and date the form as well.
12. Make copies of the completed form for your records and submit the original to the appropriate hospice provider or Medicare claims processing center.
13. Keep a copy of the form easily accessible for future reference or any audits.

Who needs se1631 sample hospice election?

1. The se1631 sample hospice election form is needed by individuals who wish to elect hospice care under the Medicare program.
2. This form is primarily used by patients who have a terminal illness with a life expectancy of six months or less, as certified by a physician.
3. It is typically required for individuals who want to receive hospice services in place of Medicare-covered benefits for their terminal illness.
4. Patients who have decided to seek hospice care and meet the eligibility criteria can use this form to formally declare their choice.
5. It is important to consult with healthcare professionals, such as physicians or hospice providers, to determine if the use of this form is appropriate for a particular situation.

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What is se1631 sample hospice election?

The se1631 sample hospice election is a form used to elect hospice care for Medicare beneficiaries.

Who is required to file se1631 sample hospice election?

The beneficiary or the authorized representative is required to file the se1631 sample hospice election form.

How to fill out se1631 sample hospice election?

The se1631 sample hospice election form must be completed with information about the beneficiary, the chosen hospice provider, and signed by the beneficiary or authorized representative.

What is the purpose of se1631 sample hospice election?

The purpose of the se1631 sample hospice election form is to formally elect hospice care for the Medicare beneficiary.

What information must be reported on se1631 sample hospice election?

The se1631 sample hospice election form requires information such as the beneficiary's personal details, chosen hospice provider, and the effective date of the election.