Hospice Notice of Election

A beneficiary uses this document to formally choose palliative care through a given provider. It records which coverage applies, when care begins and who the attending physician or nurse practitioner will be. Where the beneficiary cannot sign, the reason is explained and a representative signs instead.

Use this template

Patient Name

Nombre

Apellido

Under which coverage are you choosing the hospice benefit?

Medicare Medicaid Private insurance Self pay

Start of care date

Do you have an attending physician or nurse practitioner?

Yes No

Attending physician or nurse practitioner name

Nombre

Apellido

Election statement acknowledgement

Beneficiary Signature

Sign here

Agency Representative Signature

Sign here

Is the beneficiary unable to sign?

Yes No

Explain the reason

Representative Signature

Sign here

Date

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