Get Map 374

Filling out the Map 374 form is an essential process for individuals electing to receive the Medicaid Hospice Benefit. This guide provides step-by-step instructions to help users complete the form accurately and confidently, ensuring access to necessary hospice services.

Follow the steps to effectively complete the Map 374 online.

1. Press the ‘Get Form’ button to obtain the form and access it in the editor.
2. Begin by filling in the patient’s name and Medicaid identification number in the designated fields.
3. In the next section, enter the name of the facility providing hospice services and include the facility provider number.
4. Indicate the date of the election by filling in the day, month, and year.
5. Acknowledge the awareness of your incurable disease by confirming the management of symptoms and entering the name of the healthcare provider responsible for this care.
6. Designate your attending physician’s name and the hospice director's name as required.
7. List the medications that will be provided for outpatient care.
8. Review the benefits section to ensure you understand the services included under the hospice program.
9. If applicable, check the appropriate box regarding your Medicare status and complete any additional details such as dates.
10. Sign and date the form, along with a witness, as required in the signature section.
11. If you are requesting an additional benefit period or have revoked benefits previously, fill out the respective sections accordingly.
12. Once you have completed all sections, save your changes, then choose to download, print, or share the completed form as needed.

Complete your documents online to ensure timely access to the services you need.