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Hospice Election Requirements

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9 §10 and §20.2) Globe to indicate www link.

To receive hospice care, an individual (or his authorized representative) must elect it. Each hospice designs and prints its election statement. The election statement must include the following items of information:

  • Identification of the particular hospice that will provide care to the individual;
  • The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care;
  • The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election;
  • The effective date of the election; and
  • The signature of the individual or representative.

Sample Hospice Election Form

Discharge, Revocation and Transfers

Page last updated: April 4, 2008

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