A. RECIPIENT INFORMATION Name of recipient (last, first, middle initial) Primary hospice diagnosis (ICD-#): Recipient's Medicaid number Recipient's Social Security number B. HOSPICE PROVIDER INFORMATION Name of Hospice Provider Hospice Provider number C. DISCHARGE STATEMENT Hospice benefits for the above named recipient, enrolled with the above named provider since / / have terminated on / / for the following reasons: Recipient is deceased. Date o.
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How to fill out the IN State Form 48734 online
Filling out the IN State Form 48734 is a straightforward process that ensures accurate reporting of Medicaid hospice discharges. This guide provides step-by-step instructions to assist users in completing the form online with confidence.
Follow the steps to complete the form effectively.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In section A, enter the recipient information. Begin by filling in the last name, first name, and middle initial of the recipient in the provided fields. Next, input the primary hospice diagnosis using the applicable ICD code, followed by the recipient's Medicaid number and Social Security number.
- Proceed to section B to provide hospice provider information. Enter the name of the hospice provider and the respective hospice provider number in the designated areas.
- In section C, fill out the discharge statement. Indicate the start date of hospice benefits for the recipient. Next, provide the termination date of these benefits. Choose from the listed reasons for discharge, including recipient's death or prognosis changes, and provide further explanations if necessary. Attach relevant documentation when applicable.
- Finally, ensure that the medical director or patient care coordinator signs and dates the form, confirming the accuracy of the information provided.
- Once all sections are completed, review the form for any missing information, save your changes, and choose to download, print, or share the completed form as required.
Take the next step in managing your documents by filling out the IN State Form 48734 online today.
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