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State of michigan hospice membership notice form

State of michigan hospice membership notice form 2026

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The document is a Hospice Membership Notice (DCH-1074) used by hospice agencies in Michigan to notify the Department of Health and Human Services about a beneficiary's enrollment, disenrollment, or updates regarding hospice services. It includes sections for provider information, facility details, beneficiary data, and remarks. The form must be submitted within five days of the effective date and requires signatures to certify understanding of the conditions of enrollment. It also outlines procedures for coordination with other services and specifies requirements for completing the form.

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Click ‘Get Form’ to open the state of Michigan hospice membership notice form in the editor.
Begin by selecting the purpose of the form at the top right corner. Choose between Enrollment Application, Enrollment Update, or Disenrollment Notice and enter the effective date.
In Section I, provide your hospice provider information including name, National Provider ID, and contact details. Ensure all fields are filled clearly.
If applicable, complete Section II for facility information by indicating whether the beneficiary is currently in a nursing facility or ventilator dependent care unit.
Proceed to Section III to fill out beneficiary information. Include their name, ID number, address, Social Security Number, and other required details.
Use Section IV for any remarks that may clarify additional information regarding the beneficiary's situation.
Finally, ensure that Section V is completed with signatures from the beneficiary or authorized representative and witnesses as required.

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