Medi-Cal Provider Manual, Part 2, Hospice Care, Medi-Cal Member Revocations

If Medi-Cal members (or their legal guardian/authorized representatives) revoke their

election of hospice services, hospice providers must inform DHCS in writing by submitting

notice of the hospice revocation using the DHCS 8052 form, which is signed by Medi-Cal

members (or their legal guardian/authorized representatives). This written notice should be

emailed to the DHCS Hospice Clerk at MCHospiceClerk@dhcs.ca.gov. Send all information

via a secure, encrypted format to maintain Medi-Cal member confidentiality and ensure

compliance with all applicable state and federal privacy requirements related to PII and PHI.

Note: ‹‹If Medi-Cal members re-elect hospice care, hospice providers must submit a new

Medi-Cal Hospice Program Attestation Form through the secure, online Medi-Cal

Provider Portal to DHCS as described in more detail above in this section.›› Hospice

providers must retain the initial certification of terminal illness from the hospice

physician in Medi-Cal members’ medical records, which are to be made available to

DHCS upon request or in the event of a state or federal audit. ‹‹The hospice care

period starts again consistent with the policy in this section.››

Medi-Cal Member Discharges

‹‹If Medi-Cal members are discharged from hospice services due to either death or a

decision made by Medi-Cal members (or their legal guardian/authorized representatives) or

their hospice care team, hospice providers must inform DHCS in writing by submitting notice

of the discharge. This written notice should be emailed to the DHCS Hospice Clerk at

MCHospiceClerk@dhcs.ca.gov. Please make sure to send all information via a secure,

encrypted format to maintain Medi-Cal member confidentiality and ensure compliance with

all applicable state and federal privacy requirements related to PII and PHI.