State Form 48737 PDF Details

The State 48737 form, known as the Medicaid Hospice Election form, serves a critical purpose for individuals choosing hospice care under Medicaid. This document outlines the rights and obligations of the recipient, detailing the Medicaid hospice benefits and the process for electing these services. It requires comprehensive input, including recipient information, provider details, and clear statements regarding the benefit periods and what services are waived upon election. The form emphasizes confidentiality under specific Indiana Administrative Codes, ensuring that personal information is protected. It provides an initial 90-day benefit period, followed by another 90 days and indefinite 60-day periods thereafter, allowing for continual care based on eligibility. Furthermore, the document explains the recipient's right to revoke the hospice benefit at any time and outlines the circumstances under which other Medicaid services can be resumed. Additionally, it details the options and procedures for changing hospice providers and notes special considerations for Medicare recipients. By signing the election statement on the form, recipients acknowledge their understanding and acceptance of these terms, marking a significant step in their care journey. This form highlights the intersection of healthcare decisions and legal documentation, emphasizing the importance of informed consent in the provision of hospice care.

QuestionAnswer
Form NameState Form 48737
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedicaid hospice election 11 04 maryland medicaid hospice benefit election forms

Form Preview Example

MEDICAID HOSPICE ELECTION

State Form 48737 (R / 11-04) / OMPP 0005

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.

Effective date of Hospice Care

Medicaid Hospice effective date (State use only)

Signature of Hospice Analyst

A. RECIPIENT INFORMATION

 

 

Primary hospice diagnosis (ICD-#):

 

 

 

 

 

 

 

 

 

 

 

Name of recipient (last, first, middle initial)

 

 

Recipient's Medicaid number

 

 

 

 

 

 

Address or other location if not private home (number and street, apt. number, city, state, ZIP code)

 

 

 

 

 

 

Recipient's Social Security number

Telephone number

 

 

Date of birth (month, day, year)

 

(

)

 

 

 

 

 

 

 

 

 

Name of parent, legal guardian or representative

 

 

Sex of recipient:

 

 

 

 

Male

Female

 

 

 

 

 

 

B. PROVIDER'S INFORMATION

Date of physician's verbal approval of hospice care (month, day, year)

Name of Hospice Provider

Medicaid Hospice Provider number

Name of Attending Physician

Hospice telephone number

Attending Physician Medicaid Provider number

(If applicable) Name of Nursing Facility

Nursing Facility Medicaid Provider number

C. HOSPICE BENEFIT INFORMATION

1st Period (90 days)

2nd Period (90 days)

Indefinate number of 60 day periods (circle as appropriate)

 

1st 60 days

2nd 60 days

3rd 60 days

4th 60 days

D. ELECTION STATEMENT

(a)The Indiana Medicaid hospice benefit has been explained to me. I have been given the opportunity to discuss the services, benefits, requirements and limitation of this program and the terms of the election statement;

(b)I understand that by signing this election statement I waive all rights to regular Medicaid services except for payment to my attending physician and prior authorized treatment for services unrelated to my terminal illness, medical transportation unrelated to the terminal illness, dental services and Medicaid pharmacy services for prescriptions not covered under hospice;

(c)I understand that I will be entitled to Medicaid hospice services as long as I am Medicaid eligible. The benefit will be provided in three benefit periods of an initial 90 days, a subsequent 90 days, and an unlimited period consisting of successive 60 day periods. I may qualify for each of these periods after review by the Indiana Office of Medicaid Policy and Planning and its contractor;

(d)I understand that I may revoke the hospice benefit at any time by completing a Hospice Revocation Form, specifying the date when the revocation is to be effective and submitting the form to the hospice provider at the time of revocation. I also understand that if I choose to revoke services for a benefit period, I am not entitled to coverage of the remaining days of that benefit period. At the time I revoke hospice services, I understand my rights to other Medicaid services will resume, provided that I continue to be Medicaid eligible;

(e)I understand that I may change the designated hospice provider one time per election period without affecting the provision of my hospice benefit and that to do so my hospice provider is required to fill out a Change of Hospice Provider Form;

(f)I understand that if I am a Medicare recipient, I must elect to use the Medicare hospice benefit.

E. SIGNATURES

Signature of recipient (or recipient representative)

Date (month, day, year)

(See reverse side for the Election Statement in large print)

E. LARGE PRINT OF ELECTION STATEMENT

ELECTION STATEMENT

(a)The Indiana Medicaid hospice benefit has been explained to me. I have been given the opportunity to discuss the services, benefits, requirements and limitation of this program and the terms of the election statement;

(b)I understand that by signing this election statement I waive all rights to regular Medicaid services except for payment to my attending physician and prior authorized treatment for services unrelated to my terminal illness, medical transportation unrelated to the terminal illness, dental services and Medicaid pharmacy services for prescriptions not covered under hospice;

(c)I understand that I will be entitled to Medicaid hospice services as long as I am Medicaid eligible. The benefit will be provided in three benefit periods of an initial 90 days, a subsequent 90 days, and an unlimited period consisting of successive 60 day periods. I may qualify for each of these periods after review by the Indiana Office of Medicaid Policy and Planning and its contractor;

(d)I understand that I may revoke the hospice benefit at any time by completing a Hospice Revocation Form, specifying the date when the revocation is to be effective and submitting the form to the hospice provider at the time of revocation. I also understand that if I choose to revoke services for a benefit period, I am not entitled to coverage of the remaining days of that benefit period. At the time I revoke hospice services, I understand my rights to other Medicaid services will resume, provided that I continue to be Medicaid eligible;

(e)I understand that I may change the designated hospice provider one time per election period without affecting the provision of my hospice benefit and that to do so my hospice provider is required to fill out a Change of Hospice Provider Form;

(f)I understand that if I am a Medicare recipient, I must elect to use the Medicare hospice benefit.

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1. Complete your State Form 48737 with a selection of major fields. Collect all of the required information and make certain nothing is overlooked!

Writing section 1 in State Form 48737

2. Just after filling out the last step, head on to the subsequent stage and fill in the necessary particulars in all these fields - Attending Physician Medicaid, If applicable Name of Nursing, Nursing Facility Medicaid Provider, C HOSPICE BENEFIT INFORMATION, st Period days, nd Period days, Indefinate number of day periods, st days, nd days, rd days, th days, D ELECTION STATEMENT, The Indiana Medicaid hospice, E SIGNATURES, and Signature of recipient or.

Stage # 2 in filling out State Form 48737

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