Get Hospice Enrollment /disenrollment Authorization Request

Filling out the Hospice Enrollment /Disenrollment Authorization Request is an essential step in managing hospice care. This guide will help you navigate the online process to ensure that you complete the form accurately and effectively.

Follow the steps to complete the form correctly.

1. Use the ‘Get Form’ button to access the Hospice Enrollment /Disenrollment Authorization Request. Open the form in your online document editor.
2. Ensure you enter the recipient's information, including 'To', 'From', 'Contact Person', and appropriate phone and fax numbers, ensuring all sections are filled out legibly.
3. In the provider information section, input the 'Provider Name' and 'Provider NPI Number' accurately. This information is necessary for processing.
4. For the individual information, fill out the 'Individual Name' and 'Individual Medicaid Number'. Remember, an active Medicaid number is required for the request to be processed.
5. Record the 'Date individual/representative signed hospice election' and the 'Date Attending Physician signed DMAS 420'. If applicable, note that the attending physician signature is not required if the individual is re-electing hospice benefits.
6. Indicate whether there is a change in hospice providers by selecting 'Yes' or 'No'.
7. If applicable, complete the 'Date of hospice disenrollment/revocation/termination' and provide the 'Reason for disenrollment/revocation/termination'.
8. After filling out all required fields, review your completed form to ensure there are no errors. Save your changes to the document.
9. You can then download, print, or share the completed form as needed, ensuring it is submitted via fax to the numbers provided.

Complete your Hospice Enrollment /Disenrollment Authorization Request online today to ensure timely processing.