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Hospice revocation form pdf 2026

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Click ‘Get Form’ to open the hospice revocation form in our platform's editor.
Begin by entering the Patient Name and ID# in the designated fields at the top of the form.
Fill in the Date and Time when you are completing the form.
Indicate your decision to revoke Medicare coverage by filling in the benefit period number you wish to revoke.
Acknowledge that you understand forfeiting days of coverage by checking the appropriate box next to 'I understand that I am forfeiting the right to _ days of Hospice coverage.'
Specify an effective date for this revocation by entering it in the format _/_/_.
Provide a reason for revoking your benefit in the space provided.
Sign as either Beneficiary or Legal Representative, and include the date of signing.
If applicable, indicate your relationship to the beneficiary and have a witness sign and date where required.

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