DE · guidance
Del. Medical Assistance Program Hospice Provider Specific Policy Manual § 11.0
Appendix B – Patient’s Expiration Date
Form 2 – Patient’s Expiration Date
To: Medicaid Services Specialist
From: NPI:
(Provider name) (Provider Number)
Hospice Signature: Date:
(Name of person filling out this form)
Patient's Name: Patient's Medicaid ID#:
Hospice Election Date: Patient’s Expiration Date:
Total Number of Billable Days:
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 available upon request.
Provenance
- Source
- medicaidpublications.dhss.delaware.gov
- Retrieved
- 2026-10-01
- Edition
- dmap-hospice-2023-07-01
- Content hash
3cb1456744ae90abfa51d329a805e3d01c89f753d71585d082bd3b077e72c633
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