Medi-Cal Provider Manual, Part 2, Hospice Care, Hospice Notice of Election

The Department of Health Care Services (DHCS) requires all hospice providers to use the

Medi-Cal Hospice Program Election Notice (DHCS 8052), which is used by hospice

providers to document Medi-Cal fee-for-service members’ election of hospice care, their

informed consent, and their original signature (or that of their legal guardian/authorized

representative). The Medi-Cal Hospice Program Election Notice may only be completed by

Qualified Hospice Personnel (QHP), which is defined in Health and Safety Code (HSC)

section 1746.50 to include the following: physicians, registered nurses, licensed vocational

nurses, medical social workers, chaplains and counselors. The DHCS 8052 must be

retained in the Medi-Cal member’s medical record and made available to DHCS upon

request or in the event of a state or federal audit.

‹‹In addition to the Medi-Cal Hospice Program Election Notice, the Medi-Cal Hospice

Program Attestation Form, which serves as the official notification to DHCS that Medi-Cal

fee-for-service members have elected hospice services, must be completed and submitted

through the online, secure Medi-Cal Provider Portal within five (5) calendar days of Medi-Cal

members’ hospice election date. In submitting the Medi-Cal Hospice Program Attestation

Form to DHCS, hospice providers attest that all Medi-Cal policy and applicable state and

CMS requirements have been satisfied.››

For more information on the hospice election process, refer to the “Hospice Provider

Responsibilities” and “Submission Requirement” policy in this section.