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Hospice revocation form

Hospice revocation form pdf 2026

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The document outlines the process for revoking Medicaid hospice services, detailing recipient and provider information, a revocation statement that explains the implications of signing, and includes sections for signatures of the recipient and a witness.

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Click ‘Get Form’ to open the hospice revocation form in our platform's editor.
Begin by filling out the 'Recipient Information' section. Enter the recipient's name, primary hospice diagnosis (ICD-#), Medicaid number, and Social Security number accurately.
Next, move to the 'Provider Information' section. Input the name of the Hospice Provider and their Medicaid Provider number.
In the 'Revocation Statement' section, read through each point carefully. Ensure you understand what revoking hospice services entails before signing.
Proceed to the 'Signatures' section. The recipient or their representative must sign and date the form. A witness must also sign and date it for validation.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can you reverse a hospice decision?

Speak with your hospice doctor if you are interested in stopping. If you end your hospice care, you will be asked to sign a form that includes the date such care will end. Afterwards, you will again receive Medicare the way you did before choosing hospice, either through Original Medicare.

What is the revocation rate for hospice patients?

Patients enrolled in the Medicare Hospice Benefit can initiate disenrollment if they decide to pursue care outside what is provided by the hospice program, termed revocation [1]. In 2021, 6.3% of all hospice discharges were due to beneficiary revocation [2].

How many times can you revoke hospice?

An individual may revoke their hospice election at any time, and also re-elect hospice care at a later time. An individual has a right to request an election statement addendum from their hospice provider at any time.

What is a revocation form for hospice?

A hospice revocation is a beneficiarys choice to no longer receive Medicare covered hospice benefits. To revoke the election of hospice care, the beneficiary/representative must give a signed written statement of revocation to the hospice.

How to prevent hospice revocation?

By proactively identifying patients at risk of revocation and working to address their needs for education, additional visits, and other resources, agencies can help patients continue to receive the best possible care in the right setting.

hospice revocation code 0

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