Get Caloptima Hospice Notification/validation Form. Caloptima Hospice Notification/validation Form

Completing the CalOptima Hospice Notification/Validation Form is an essential step in the hospice care process. This guide provides clear, step-by-step instructions to ensure you fill out the form correctly and efficiently.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter the patient’s name, including their last and first names, along with their mailing address, city, ZIP code, social security number, date of birth, and age. Ensure this information is accurate and complete.
3. Continue in Section I by filling out the patient’s client index number, phone number, aid code, and the hospice provider information including the physician's name, address, and phone number. If available, include the physician's Medi-Cal ID number and the Medi-Cal provider ID number.
4. In Section II, specify the diagnosis code and county code. This may require consultation with medical staff to ensure correct coding.
5. In Section III, indicate the type of hospice billing codes applicable to the patient's care, such as routine home care or continuous home care. Assign the number of units (days) associated with the service being provided.
6. Choose the appropriate place of service, indicating whether it is a skilled nursing facility (SNF) or home care. If a skilled nursing facility is involved, provide the facility's name.
7. In Section IV, document any attached items as required, such as the written order signed by the attending physician, the patient’s hospice election form, initial written plan of care, certification of terminal illness by a medical doctor, DHS 6194, and documentation of the face-to-face encounter.
8. Include the election date, revocation date, and expiration date if applicable. Finally, ensure all required information is included before finalizing.
9. Once all sections are completed, review the entire form for accuracy and completeness. Save changes, then either download, print, or share the completed form as necessary.

Complete the CalOptima Hospice Notification/Validation Form online today to ensure timely processing of hospice services.