Kan. Medical Assistance Program Hospice Fee-for-Service Provider Manual § 8400, Forms

Forms which must be kept on file at the hospice:

• CERTIFICATION STATEMENT - certifies the member is terminally ill.

• ELECTION STATEMENT - verifies the member has elected hospice care and the name of

the hospice which will provide care.

• REVOCATION STATEMENT - shows the member has revoked hospice care and is entitled

to regular KMAP benefits.

• CHANGE OF HOSPICE - shows the member has elected another hospice to provide care.

• NOTIFICATION OF DEATH - verifies the member’s date of death.

All forms must include the following information:

• Member name

• Member date of birth

• Member Medicaid ID number

• Hospice provider’s name and ID number

• Hospice start of care/effective date

• Member’s or legal representative’s signature

• Date of signature