Tip for Transfer Form

Patients can only transfer once per benefit period — plan carefully

Tip for Transfer Form

Ensure continuity of care by coordinating the transfer between the two hospice providers

Tip for Transfer Form

The new hospice provider should receive the patient's medical records and current plan of care

Hospiceeasy

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.

Form Details

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Where to Submit This Form

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Patient signs a transfer statement with the new hospice provider

The patient can transfer to a different hospice provider once per benefit period.

Filing Deadline

Can be done once per benefit period. Effective on the date specified by the patient.

Required Attachments

📎 Signed transfer statement from the patient or authorized representative
📎 Name of the new hospice provider
📎 Effective date of the transfer

Processing Time

Immediate. The new hospice provider assumes responsibility on the transfer date. Both providers submit appropriate notices to CMS.

What Happens Next

The original hospice provider files a NOTR. The new hospice provider files a new NOE. Medical records are transferred to the new provider. The new hospice provider assumes all care responsibilities on the transfer date.

Tips for This Form

✓ Patients can only transfer once per benefit period — plan carefully
✓ Ensure continuity of care by coordinating the transfer between the two hospice providers
✓ The new hospice provider should receive the patient's medical records and current plan of care
✓ Transfer does not reset the benefit period — it continues where it left off

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 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.

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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