Form Mc0298 24 PDF Details

At the heart of facilitating dignified care and ensuring legal compliance for hospice patients nearing the end of life outside of hospital or licensed nursing home settings, lies the MC0298-24 form. Created by the Southern Minnesota Regional Medical Examiner’s Office, this document serves as a critical pre-registration tool, setting a structured pathway for hospice care providers. It mandates thorough data collection, encompassing patient details from full legal name to specific medical conditions, thereby streamlining the process for both the medical examiners and the caregivers. The requirements stretch from recording the patient's demographic information—like their address and birth date—to the more sensitive aspects such as the anticipated terminal diagnoses and any significant changes in the patient’s condition, like falls or injuries. Medical examiner offices, through this form, also probe the realms of post-mortem wishes, inquiring about the patient's interest in eye or tissue donation, making it a comprehensive document that bridges patient care with legal protocols. What’s more, it requires the details of the attending physician and legal next-of-kin or legally appointed person under MN Statute 145C, ensuring all stakeholders are included in the end-of-life care continuum. To the uninitiated, the form may appear as mere paperwork, yet it embodies the intricate balance between care, respect, and legality that surrounds the final chapter of a patient’s life journey.

QuestionAnswer
Form NameForm Mc0298 24
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesxxx, pre, Diagnoses, mayo mc0298

Form Preview Example

Pre-Registration

Southern Minnesota Regional Medical Examiner’s Office

For hospice patients expected to die outside of a hospital or licensed nursing home facility.

Instructions: Please type or print clearly and complete entirely or form will be returned. Fax to 507-266-6658.

Patient Name (Last, Full Legal First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

ZIP Code

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (xxx-xxx-xxxx)

 

 

 

 

 

Birth Date (Month DD, YYYY)

 

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

Married

Widowed

Divorced

Never Married

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal Next-of-Kin (If there is no living spouse, list any living adult children as legal next of kin.)

 

 

 

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

Legal Person Appointed Under MN Statute 145C (Please fax a copy with pre-registration form.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, Full Legal First)

 

 

 

 

 

 

 

 

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

Phone (xxx-xxx-xxxx)

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

Attending Physician (The physician who is signing the death certificate)

 

 

Clinic Name

 

 

 

 

 

 

 

 

 

 

 

 

Phone (xxx-xxx-xxxx)

 

 

 

 

 

Date Last Seen (Month DD, YYYY) (Must be within 180 days)

 

 

 

 

 

 

 

 

 

Anticipated Terminal Diagnoses and Co-Morbidities (Be Specific)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Controlled Substances Prescribed to Patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any Falls/Injuries Resulting in Fractures or Neurological Change in the Past Six Months?

Yes

No

If yes, describe

 

 

 

 

 

 

 

 

 

Registering Agency (Must be a Class D Licensed Hospice Agency)

 

 

 

 

 

 

License Number

 

 

 

 

 

 

 

 

 

 

 

 

Registered By (Last, First) (Print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (xxx-xxx-xxxx)

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the patient interested in eye or tissue donation:

Yes

No

If yes, call 1-800-24-SHARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Medical Examiner Office Use Only

 

 

 

 

 

 

 

 

 

Date Received

 

 

 

 

 

 

Accepted By

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC0298-24

How to Edit Form Mc0298 24 Online for Free

You may prepare pre without difficulty with the help of our online tool for PDF editing. To make our editor better and less complicated to use, we continuously come up with new features, with our users' feedback in mind. It just takes a few simple steps:

Step 1: Click the "Get Form" button at the top of this page to access our editor.

Step 2: This editor grants the capability to change PDF documents in a range of ways. Modify it by adding any text, correct what's originally in the PDF, and put in a signature - all within the reach of a few clicks!

In an effort to complete this PDF form, ensure that you provide the right details in each and every field:

1. Complete the pre with a selection of essential blanks. Get all the important information and be sure there is nothing missed!

Part # 1 of completing mayo mc0298

2. Once your current task is complete, take the next step – fill out all of these fields - Attending Physician The physician, Clinic Name, Phone xxxxxxxxxx, Date Last Seen Month DD YYYY Must, Anticipated Terminal Diagnoses and, Current Controlled Substances, Any FallsInjuries Resulting in, Yes, No If yes describe, Registering Agency Must be a Class, License Number, Registered By Last First Print, Phone xxxxxxxxxx, Fax, and Is the patient interested in eye with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

mayo mc0298 conclusion process outlined (part 2)

Always be very careful while filling in Registering Agency Must be a Class and Yes, because this is the part where most users make a few mistakes.

Step 3: Revise the information you've typed into the blanks and then click on the "Done" button. Make a free trial option with us and acquire instant access to pre - which you are able to then start using as you wish from your personal account page. We do not share or sell the information that you type in whenever working with documents at FormsPal.