Hospice Forms

Physician certification that the patient has a terminal illness with a prognosis of 6 months or less. Required at the start of each benefit period. Face-to-face encounter required before the third benefit period and each subsequent period.

Elects the Medicare hospice benefit. Identifies the hospice and attending physician. Acknowledges waiver of curative treatment for the terminal illness. Triggers two 90-day benefit periods followed by unlimited 60-day periods.

Electronic notification to Medicare contractor that a beneficiary has elected hospice. Must be filed within 5 calendar days of the election effective date. Late filing results in provider liability for uncovered days.

Filed when a hospice beneficiary is discharged alive or revokes the election. Must be submitted within 5 calendar days of the effective date.

Written physician order required before discharging a patient for any reason other than revocation, transfer, or death. Documents the clinical rationale for discharge.

Written statement revoking hospice election for a specific benefit period. Patient may re-elect hospice for remaining benefit periods. Verbal revocation is not acceptable; must be in writing.

Change of designated hospice provider (allowed once per election period). Not a revocation. Receiving hospice files a new NOE; benefit period dates are unaffected.