3074-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Hospice Provider Name and Contract Number in the designated fields at the top of the form.
3. Fill in the Provider Address, ensuring all details are accurate for proper identification.
4. If applicable, check the Correction box to indicate any necessary amendments.
5. Complete the Recipient Name section with Last, First, and Middle names as required.
6. Input the Election/Start Date and ensure that it aligns with other relevant dates on the form.
7. Provide necessary identification numbers such as DADS Medicaid No., Medicare No., and Social Security No. in their respective fields.
8. Select either Certification or Recertification and enter the appropriate date in MMDDYYYY format.
9. Ensure that both Hospice Staff and Attending Physician signatures are obtained where required, along with their printed names and license numbers.

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