Medicaid Hospice Discharge bFormb - indianamedicaidcom 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'A. RECIPIENT INFORMATION' section. Enter the recipient's name, primary hospice diagnosis (ICD-#), Medicaid number, and Social Security number accurately.
3. Next, move to 'B. HOSPICE PROVIDER INFORMATION'. Input the name of the hospice provider and their corresponding provider number.
4. In 'C. DISCHARGE STATEMENT', indicate the termination date of hospice benefits and select the reason for discharge from the provided options. If applicable, provide additional explanations and attach relevant documentation.
5. Finally, ensure that a Medical Director or Patient Care Coordinator signs and dates the form to validate it before submission.

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