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The Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealthMassHealth Hospice Election Form This form must be completed and submitted to the IMS Health
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How to fill out masshealth hospice election form

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How to fill out masshealth hospice election form

01
To fill out the MassHealth Hospice Election Form, follow these steps:
02
Begin by entering the patient's personal information, including name, date of birth, and Social Security number.
03
Provide the contact information of the primary caregiver or responsible party, including name, address, and phone number.
04
Specify the hospice provider by entering their name, address, and contact details.
05
Indicate the effective date of hospice care and the anticipated length of stay.
06
Sign and date the form to confirm the patient's election for MassHealth hospice care.
07
Make copies of the completed form for your records and submit it to the designated MassHealth office.

Who needs masshealth hospice election form?

01
MassHealth Hospice Election Form is required for individuals who are eligible for MassHealth and wish to elect hospice care as part of their healthcare plan.
02
It is primarily used by patients with a terminal illness who require palliative care and support in a hospice setting.
03
The form is necessary to formally declare the patient's choice to receive hospice services and to ensure proper coverage and coordination of care.
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The MassHealth Hospice Election Form is a document that allows individuals to elect hospice care coverage under the MassHealth program.
Individuals who are eligible for MassHealth benefits and wish to receive hospice care coverage are required to file the MassHealth Hospice Election Form.
The MassHealth Hospice Election Form can be filled out by providing personal information, choosing a hospice provider, and signing the form.
The purpose of the MassHealth Hospice Election Form is to allow individuals to elect hospice care coverage and receive the necessary benefits under the MassHealth program.
Information such as personal details, chosen hospice provider, and signature must be reported on the MassHealth Hospice Election Form.
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