Get Bhsf Form Hospice

Filling out the Bhsf Form Hospice online is a crucial step for individuals seeking hospice services under the Louisiana Medicaid program. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

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

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In Part I, the patient or their legal representative must complete their personal information, including the name of the chosen hospice provider and the start date for services.
3. Read and acknowledge the patient’s statement concerning hospice services. Ensure to check all applicable statements regarding eligibility and understanding of service limitations.
4. Sign and date the form in the designated areas, providing the daytime phone number of the patient or legal representative as well as their printed name.
5. In Part II, the hospice provider will need to fill in the patient's information, including their full name, address, Medicaid and Medicare ID numbers, and date of birth.
6. Complete the billing information, specifying the statement coverage period along with the primary diagnosis code(s) and all other related diagnosis codes.
7. The hospice provider should then complete the provider information section, including their name, address, phone number, and relationship to the patient.
8. Ensure all relevant signatures from the hospice provider representative and attending physician are affixed, along with the respective dates.
9. Once all sections are complete, save changes, and then download, print, or share the form as needed.

Start completing the Bhsf Form Hospice online to ensure timely access to necessary hospice services.