CMS, Hospice Information for Medicare Part D Plans (OMB 0938-1269), § Signature Requirements

1. Section 1 of the form must be signed and dated by either the hospice representative or the

prescriber when the form is utilized in the following ways:

a) to prospectively inform the Part D plan sponsor/PBM of drugs in the 4 categories that will

likely be dispensed because they are both included in the plan of care and are unrelated to

the terminal prognosis.

b) to document a change in hospice status and the appropriate signed (NOE or NOTR) is

attached

The sponsor’s/PBM’s pharmacy help desk staff may sign the form in these two instances as well

when staff complete the form based on a telephone contact with the hospice provider or

prescriber. As part of the signature process, help desk staff should sign their name and include the

name and contact information for the person who phoned in the information as well as the date the

call was received.

2. All requests for a Hospice A3 Reject Override must be signed by the prescriber, the beneficiary

or the hospice representative.

3. If Section II is completed, a hospice representative and the beneficiary/representative must sign.