Get La Bhsf Hospice-noe 2012-2025

Filling out the LA BHSF Hospice-NOE form is essential for patients seeking hospice care through the Louisiana Medicaid program. This guide will provide you with detailed instructions to ensure that you accurately complete the form and understand each section's requirements.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editing tool.
2. Begin with Part I, which must be completed by the patient or their legal representative. Clearly state the chosen hospice provider and the election/admission date using the MM-DD-YYYY format.
3. Carefully read the patient's statement regarding understanding hospice services. Confirm acceptance by signing and dating the section. Include the daytime phone number of the signer and their printed name, followed by the legal representative's relationship to the patient if applicable.
4. Move on to Part II to be completed by the hospice provider. Fill in the patient information fields, including the patient’s name, address, Medicaid ID number, Medicare ID number, date of birth, and diagnosis codes, ensuring that dates are in the MM-DD-YYYY format.
5. Provide discharge or revocation reasons as necessary. Then, complete the provider information section, which includes the hospice provider's name, number, address, and phone number, as well as the attending physician's printed name and provider numbers.
6. Finally, the hospice provider representative must sign, print their name, and date the form. Ensure all information is accurate before proceeding.
7. After all sections are thoroughly completed, save your changes. You can then download, print, or share the form as needed.

Complete your LA BHSF Hospice-NOE form online today to ensure timely access to hospice services.