Get Hospice Election Communication Form - Ucare - Ucare

Filling out the Hospice Election Communication Form is an essential step for individuals seeking hospice services through UCare. This guide provides a comprehensive walkthrough to help users complete the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling in your name in the designated field, ensuring that it matches your identification documents.
3. Indicate your gender by selecting either 'Male' or 'Female' from the options provided.
4. Enter your UCare ID number. This number is crucial for identification within the UCare system.
5. Provide your date of birth in the appropriate format to verify your age.
6. Fill in your Social Security number (SS #) in the specified field for further identification.
7. Complete the 'Completed By' section, which should reflect the name of the person filling out the form, such as the primary care coordinator (PCC).
8. Document the date the form is completed in the designated area.
9. Under the 'Hospice Admission' section, provide the name of your hospice provider and the admission date.
10. Input the correct ICD-9 code and the diagnosis related to your hospice care to ensure accurate records.
11. If changing your hospice election, note the revocation date if applicable. This is essential if you decide to revoke hospice care.
12. Indicate the term date, if the hospice has terminated your care.
13. Finally, ensure to fax this form to UCare at the provided number (612-884-2088) within 48 hours of making any elections, terminations, or revocations regarding hospice services.
14. After completing the form, you may save your changes, download a copy, print it, or share it as required.

Complete your documents online to ensure timely processing and compliance.