N.C. Medicaid Clinical Coverage Policy No. 3D § 5.6.2

The provider of hospice services shall comply with 42 CFR §418.24 (b), Content

of election statement.

The election statement must include the following information:

a. Identification of the hospice and of the attending physician that will provide

care to the beneficiary. The beneficiary shall acknowledge that the identified

attending physician was his or her choice;

b. The beneficiary’s acknowledgement that he or she has been given a full

understanding of the palliative rather than curative nature of hospice care, as it

relates to the beneficiary’s terminal illness;

c. The effective date of the election period, which may be the first day of hospice

care or a later date, but may be no earlier than the date of the election

statement;

d. The signature of the beneficiary or representative; and

e. Acknowledgement that certain Medicaid services are waived by the election

of Hospice.