Tip for Revocation Statement

Revoking hospice does NOT prevent re-election later — patients can go back on hospice at any time

Tip for Revocation Statement

The patient forfeits the remaining days in the current benefit period upon revocation

Tip for Revocation Statement

Consider whether a brief revocation for a specific treatment, followed by re-election, is appropriate

Hospiceeasy

Hospice Revocation Statement

Revocation Statement · Hospice Agency

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.

Form Details

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Where to Submit This Form

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Patient signs a written revocation statement with the hospice provider

The patient (or authorized representative) must sign a written statement revoking the hospice election.

Filing Deadline

Can be done at any time. Effective on the date specified by the patient. The patient forfeits remaining days in the current benefit period.

Required Attachments

📎 Signed written revocation statement from the patient or authorized representative
📎 Date the revocation is to be effective
📎 No other attachments required from the patient

Processing Time

Immediate. Regular Medicare benefits resume on the revocation date. The hospice provider submits a NOTR to CMS.

What Happens Next

The patient returns to regular Medicare coverage. Curative treatment for the terminal illness resumes. The patient can re-elect hospice at any time, beginning a new benefit period. The remaining days in the revoked benefit period are forfeited.

Tips for This Form

✓ Revoking hospice does NOT prevent re-election later — patients can go back on hospice at any time
✓ The patient forfeits the remaining days in the current benefit period upon revocation
✓ Consider whether a brief revocation for a specific treatment, followed by re-election, is appropriate
✓ Ensure the patient understands the implications of revocation, including financial responsibility for curative treatment

More Hospice Forms

Hospice Election Statement

Hospice Election (CMS model) · CMS / Hospice Agency

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.

Hospice Certification / Recertification

Hospice Certification (CMS) · CMS

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.

Hospice Notice of Election (NOE)

NOE (CMS electronic) · CMS

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.

Hospice Notice of Termination/Revocation (NOTR)

NOTR (CMS) · CMS

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

Hospice Transfer Form

Transfer Form · Hospice Agency

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

Hospice Physician Discharge Order

Discharge Order · Hospice Agency

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

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Hospice Agency or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.