Get Ms Dom-1166 A 2021-2025

The MS DOM-1166 A is an important form for individuals using hospice services. This guide provides clear, step-by-step instructions to help you navigate the online filling process effectively.

Follow the steps to complete the MS DOM-1166 A online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin filling out the beneficiary information. Enter the name, address, and contact number of the person receiving hospice services. If applicable, provide the name of their guardian or legal representative, along with their relationship to the beneficiary.
3. Provide the name of the beneficiary's attending physician, along with their contact number. This information is important for ensuring proper coordination of care.
4. Complete the hospice provider information section by entering the name and address of the hospice provider offering care.
5. Select a reason for the revocation or discharge by completing either Box 1 or Box 2. For Box 1, read and understand the beneficiary revocation statement, then sign and date it appropriately.
6. If you are filling out Box 2 for hospice discharge, indicate the admission and discharge dates of the beneficiary. Provide a reason for discharge and include any necessary explanations in the space provided.
7. If applicable, ensure all relevant information regarding compliance, transfers, and conditions is documented as required. Sign and date where indicated for both the beneficiary or guardian and the hospice staff.
8. After completing all sections of the form, review your entries for accuracy. Save changes, and you have the option to download, print, or share the completed form.

Begin filling out the MS DOM-1166 A online today to ensure timely processing of your hospice services.