Iowa Medicaid Hospice Provider Manual, APPENDIX C

Click here to view the form online.

A. Purpose of Revocation of Medicaid Hospice Benefit

If a member or legal representative wants to stop receiving hospice services, this

form is completed.

A member or legal representative may revoke services at any time. The member

may choose to begin hospice services at any time after a revocation also.

B. When the Form Must be Completed

This form must be completed when a conscious decision by the member or legal

representative is made to stop receiving hospice services.

A revocation does not include ineligibility for the hospice benefit or death (see

Discharge from Hospice).

C. Responsibility for Completion

The hospice provider may assist the member or the legal representative with

completion of this form, if needed. The member or the legal representative must

sign and date the form.

D. Instructions

Recipient’s name and Medicaid number. Enter the member’s state

identification (SID) number as it appears on the Medical Assistance Eligibility Card.

This number consists of seven numeric characters and an ending alphabetic

character.

If the member has both Medicare and Medicaid eligibility, add the member’s

Medicare number under the member’s SID.

Agency name and Agency provider number. Enter the hospice agency’s name

and the hospice agency’s Iowa Medicaid provider number in the spaces provided.

Recipient’s signature. The signature of the member or legal representative.

Date. The member or legal representative must write the date the form was

signed.

Witness’ signature. The person who witnessed the member’s or legal

representative’s signature must sign this form.

• A legal representative who witnessed the member’s signature can sign this

form.

• A hospice staff who witnessed the member’s or the legal representative’s

signature cannot sign as a witness for this form.

Witness’ signature. The signature of the person who witnessed the member’s

sign this form is required.

Date. The witness must date this form.

• A legal representative who witnessed the member’s signature can date this

form.

• A hospice staff who witnessed the member’s or the legal representative’s

signature cannot date this form.

E. Distribution

• Keep the original in the member’s case file.

• Submit a copy to the member or the legal representative.

• If the member resides in an NF, submit a copy to the:

• Nursing facility.

• DHS CFEU within two days of action by mail, fax or email per the

information below:

Mailing Address:

DHS CFEU

Imaging Center 1

Iowa Department of Human Services

417 E. Kanesville Blvd.

Council Bluffs, IA 51503-4470

Fax: (515) 564-4040

Email: facilities@dhs.state.ia.us