Get Hospice Certification Form - Blue Cross And Blue Shield Of Alabama - Bcbsal

Filling out the Hospice Certification Form is an essential step in securing hospice services for individuals in need. This guide will provide clear instructions on how to complete the form accurately and efficiently online to ensure a smooth certification process.

Follow the steps to fill out the Hospice Certification Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the hospice in the designated field at the top of the form.
3. Fill out the patient information section, including the patient’s name, address, telephone number, date of birth, name of the contract holder, primary caregiver details, and contract number.
4. Indicate the patient’s primary and secondary diagnoses, including the corresponding ICD9 codes.
5. Provide the date the hospice care is set to begin.
6. Select the place of care by marking either home care, inpatient hospice, or respite care, and indicate the appropriate checkbox.
7. In the services provided section, check all services that apply along with their frequency.
8. Complete the clinical section with disease-specific information, including symptom specifics, vital signs, and a brief description of the patient's condition.
9. List all medications the patient is currently taking, noting the dosage and whether each is covered by hospice.
10. Indicate if the patient is no longer seeking aggressive treatment and if a Do Not Resuscitate (DNR) form has been signed.
11. Provide information on any home health or hospice services the patient has received in the last six months.
12. Complete the ordering physician's details, including their name, provider number, and office address.
13. Fill out the hospice identification and certification section with the necessary hospice details.
14. Once all information is complete, review the form for accuracy, then save changes, download, or print to retain a copy.

Start filling out the Hospice Certification Form online today to ensure timely access to necessary services.