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UCARE FOR SENIORS/MSHO/UCare Connect HOSPICE ELECTION COMMUNICATION FORM Fax To: UCare Medicare Enrollment at 612-884-2088 Name Male UCare ID # Female Date of Birth SS # Completed By: PCC Date: HOSPICE.

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PLAN OF CARE (POC) The POC must include all services necessary for the palliation and management of the terminal illness and related conditions of the individual. The hospice POC should link with the needs identified in the initial/comprehensive assessment.

The election statement addendum must include the following: (1) The addendum must be titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” (2) Name of the hospice. (3) Individual's name and hospice medical record identifier.

Hospice care is for people with a life expectancy of 6 months or less (if the illness runs its normal course). If you live longer than 6 months, you can still get hospice care as long as the hospice medical director or other hospice doctor recertifies that you're terminally ill.

I acknowledge that I have been given a full explanation and have an understanding of the purpose of hospice care. Hospice care is to relieve pain and other symptoms related to my terminal illness and related conditions and such care will not be directed toward cure.

The purpose of this addendum is to notify beneficiary (or representative), in writing, of those conditions, items, services, and drugs the hospice will not be covering because the hospice has determined they are unrelated to the individuals terminal illness and related conditions.

The election statement must include the patient's choice of attending physician. The information identifying the attending physician should be recorded on the election statement in enough detail so that it is clear which physician or NP was designated as the attending physician.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232