Free 48734.PDF - Indiana

MEDICAID HOSPICE DISCHARGE
State Form 48734 (R / 12-02) / OMPP 0008

The information contained on this completed form is CONFIDENTIAL according to 405 IAC 1-16, 5-2-10.1, 5-2-10.2, 5-5-1, and 5-34.

A. RECIPIENT INFORMATION
Name of recipient (last, first, middle initial) Recipient's Social Security number

Primary hospice diagnosis (ICD-#):

Recipient's Medicaid number

B. HOSPICE PROVIDER INFORMATION
Name of Hospice Provider Hospice Provider number

C. DISCHARGE STATEMENT Hospice benefits for the above named recipient, enrolled with the above named provider since ______ / _______ / ______ have terminated on ______ / ______ /______ for the following reasons:

Recipient is deceased. Date of death was ______ / ______ / _______ . Prognosis is now greater than six months. Safety of recipient or hospice staff is compromised (explain below and attach revelent documentaion). Recipient moved out of service area. Other (explain below)

Signature of Medical Director or Patient Care Coordinator

Date