DE · guidance
Del. Medical Assistance Program Hospice Provider Specific Policy Manual § 12.0
Appendix C – Patient’s Revocation Date
Form 3 – Patient’s Revocation Date
To: Medicaid Services Specialist
From: NPI:
(Provider name) (Provider Number)
Hospice Representative: Date:
(Name of person filling out this form)
Patient's Name: Patient's Medicaid ID#:
Hospice Election Date: Patient’s Revocation 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.
Nursing Home Responsibilities
Provenance
- Source
- medicaidpublications.dhss.delaware.gov
- Retrieved
- 2026-10-01
- Edition
- dmap-hospice-2023-07-01
- Content hash
98347e6f58f0098e9b46d5004fd370809da5efc77c201d315b48f4cde63862a5
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