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SENIOR & LONG TERM CARE DIVISION COMMUNITY SERVICES BUREAU Medicaid Hospice Election of Hospice Form Example Medicaid Hospices may design their Hospice Election Statements. Hospice election statements
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How to fill out hospice 404-1 election of
How to fill out hospice 404-1 election of
01
To fill out hospice 404-1 election form, follow these steps:
02
Obtain the form from your hospice provider or download it from the official website.
03
Write your name, address, and contact information in the designated fields.
04
Indicate the date of the election and the effective date of hospice care.
05
Provide information about your attending physician and the hospice provider.
06
Specify the level of care desired (routine home care, continuous home care, inpatient respite care, or general inpatient care).
07
Sign and date the form, and ensure that your attending physician also signs it.
08
Submit the completed form to your hospice provider for processing.
Who needs hospice 404-1 election of?
01
Hospice 404-1 election form is needed by individuals who wish to elect hospice care.
02
It is typically used by patients who are terminally ill and have a life expectancy of six months or less.
03
The form is also required for individuals who want to change their level of hospice care or switch hospice providers.
04
Family members or legal representatives may also need to fill out this form on behalf of the patient.
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What is hospice 404-1 election of?
Hospice 404-1 election is an election made by a hospice patient to receive hospice care services.
Who is required to file hospice 404-1 election of?
The hospice patient is required to file hospice 404-1 election.
How to fill out hospice 404-1 election of?
Hospice 404-1 election form can be filled out by the hospice patient with the assistance of their healthcare provider.
What is the purpose of hospice 404-1 election of?
The purpose of hospice 404-1 election is to formalize the patient's choice to receive hospice care services.
What information must be reported on hospice 404-1 election of?
The hospice 404-1 election form requires information such as the patient's name, signature, date of election, and certification by the attending physician.
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