Ind. IHCP Hospice Services Provider Reference Module, Section 5, Additional Hospice Authorization Forms

The following forms are available in the Hospice Forms section of the Forms page at in.gov/medicaid/providers:

• Hospice Provider Change Request Between Indiana Hospice Providers form

• Change in Status of Medicaid Hospice Patient form

• Medicaid Hospice Revocation form

• Medicaid Hospice Discharge form

When submitting any of these forms by fax or mail, providers must complete a Prior Authorization

Revision Request Form and attach it to the front of the appropriate completed form. The Prior

Authorization Revision Request Form can be obtained from the Prior Authorization section of the Forms

page.

Alternatively, the requesting provider for the existing authorization may upload the appropriate form via

the FFS PA-UM provider portal as an authorization revision.