Free 48735.pdf - Indiana

MEDICAID HOSPICE REVOCATION
State Form 48735 (4-98) / OMPP 0007

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

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

Primary hospice diagnosis (ICD-#):

Recipient's Medicaid number

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

C. REVOCATION STATEMENT (a) The Medicaid Hospice Program has been explained to me. I have been given the opportunity to discuss the services, benefits, requirements and limitations of this program and the terms of the revocation of these services; (b) I understand that by signing this revocation statement I will, if eligible, resume Medicaid coverage of benefits waived when the hospice care was elected; (c) I will forfeit ALL hospice coverage days remaining in this benefit period; (d) I may at any time elect to receive hospice coverage for any other hospice benefit period for which I am eligible.

D. SIGNATURES
Signature of recipient (or recipient representative) Date

Signature of witness

Date