Hospice Membership Notice - State of Michigan - michigan 2026

1. Click ‘Get Form’ to open the Hospice Membership Notice in the editor.
2. Begin by selecting the purpose of the form at the top right corner: Enrollment Application, Enrollment Update, or Disenrollment Notice. Enter the effective date for your selection.
3. In Section I, provide detailed information about the hospice provider including name, National Provider ID, address, and contact details.
4. If applicable, complete Section II with facility information if the beneficiary is currently in a nursing facility. Include facility name and address.
5. In Section III, fill out beneficiary information such as name, ID number, address, birth date, and gender. Ensure all fields are accurately completed.
6. Use Section IV for any additional remarks that may clarify beneficiary circumstances or service coordination needs.
7. Finally, ensure signatures are obtained in Section V from the beneficiary or authorized representative to certify understanding of enrollment conditions.

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