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03. Share your form with others
Send hospice patient via email, link, or fax. You can also download it, export it or print it out.
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Click ‘Get Form’ to open the cms 417 in the editor.
Begin by filling out Item I, providing the name of your hospice and its street address. Ensure that you insert the six-digit Medicare Certification Number if applicable.
In Item IV, indicate how services are provided. Place a '1' for direct services, '2' for outside sources, or '3' for both. This helps clarify your service delivery model.
Complete the sections regarding the type of control and number of employees/volunteers. Be sure to check all relevant boxes that apply to your hospice's structure.
Finally, review all entries for accuracy before signing and dating the form at the bottom. Retain a copy for your records and submit it to your State Agency as instructed.
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