Medicaid Hospice Discharge bFormb - indianamedicaidcom: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
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.
Next, move to 'B. HOSPICE PROVIDER INFORMATION'. Input the name of the hospice provider and their corresponding provider number.
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.
Finally, ensure that a Medical Director or Patient Care Coordinator signs and dates the form to validate it before submission.

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How do I contact Indiana Medicaid?

If there are questions about this information, contact EDS Customer Assistance at (317) 655-3240 in the Indianapolis local area or 1-800-577-1278. The quick reference is also available on the IHCP Web site at .indianamedicaid.com.

Is hospice care covered under Medicaid?

Hospice services are available in every state through Medicaid and you can find information about those benefits on Medicaid.gov. Additionally, the Centers for Medicare Medicaid Services has prepared a downloadable PDF with more information on the hospice benefit and patients rights.

How do I talk to a human at Medicaid?

Contact Details Organization Type:State Medical Assistance Office Organization Name: Family and Social Services Administration of Indiana Organization Description: Medicaid program Covered States and Territories: Indiana1 more row

How to disenroll from Medicaid Indiana?

By mail, using the IHCP Provider Disenrollment Form: The disenrollment form is an interactive PDF file, allowing you to type information into the fields from your computer, save the completed file to your computer, and print the file for signatures and mailing.