Get Managed Care Hospice Election Revocation Form - Peach State ...

Filling out the Managed Care Hospice Election Revocation Form is an important step for ensuring that you manage your hospice services effectively. This guide provides clear, step-by-step instructions on how to complete the form online, catering to users with varying levels of experience.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to access the Managed Care Hospice Election Revocation Form and open it in your preferred editor.
2. Begin by completing Section I, which includes member information. Fill in the member's name, Medicaid number, date of birth, CMO ID (if applicable), and any additional relevant information.
3. Next, provide the hospice information. Include the facility's name, phone number, fax number, address, city/state, the attending physician's name, zip code, and Medicaid provider number. Make sure to also include relevant clinical information and the diagnosis (ICD-9 code).
4. Proceed to Section II and complete the member statement. This section requires the member or representative to acknowledge their understanding of the election statement, payment responsibilities, and their right to discontinue hospice care.
5. Fill in the print name and signature fields for both the member or representative and the hospice representative, including the relevant dates.
6. Move to Section III and complete the revocation statement. Indicate your desire to revoke hospice coverage and understand the implications of this decision.
7. Provide the effective date of revocation, along with the print name and signature fields for both the member or representative and the hospice representative, again including the relevant dates.
8. Finally, review all entered information for accuracy and completeness. After confirming everything is correct, you can save the changes, download, print, or share the completed form.

Start filling out your Managed Care Hospice Election Revocation Form online now.