DE · guidance
Del. Medical Assistance Program Hospice Provider Specific Policy Manual § 10.0
Appendix A – Patient’s Hospice Activity Dates
Form 1 – Patient’s Hospice Election Information
To: Medicaid Services Specialist
From: NPI:
(Provider name) (Provider Number)
Hospice Signature: Date:
(Name of person filling out this form)
Patient's Name: Terminal Dx:
Patient's Medicaid ID#: Hospice Election Date:
Attending Physician: Hospice Employee/Volunteer: Yes
No
(Print Physician name)
The form must be submitted with the following documentation:
• Physician Certification of Terminal Illness
• Election Statement
• Physician's Plan of Care
Send this form and required documentation by one of the following
formats: 1) secure email*; 2) FAX*; or 3) USPS mail to Division of
Medicaid & Medical Assistance, Attention: Medicaid Services
Specialist, Robscott Building – 2A, 153 E. Chestnut Hill Road, Newark,
DE, 19713.
* Contact the Medicaid Services Specialist for this information.
NOTES:
• DMMA must be notified immediately of hospice election/change.
• Electronic copy of this form is available upon request.
• Incomplete information will result in termination of hospice benefit.
Provenance
- Source
- medicaidpublications.dhss.delaware.gov
- Retrieved
- 2026-10-01
- Edition
- dmap-hospice-2023-07-01
- Content hash
915c55620a60156f3171d32e5f31bcad60e3a69b828133f34fdfcd792acf43b3
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