Va. DMAS Hospice Provider Manual ch. IV, How To Access Dmas Hospice Forms

There are four hospice DMAS forms, including: (1) the Request for Hospice Benefits

(DMAS 420); (2) the Physician Recertification (DMAS 420A); (3) the Hospice Benefits

Change/Revocation/Termination Statement (DMAS 421); and (4) the Hospice

Enrollment/Disenrollment Authorization Request (DMAS 421A). The current versions of

these forms are available on the Virginia Medicaid Portal located online at:

www.virginiamedicaid.dmas.virginia.gov. To access the forms, visit the portal and click

on the “Provider Services” tab highlighted in blue on the right side of the page. Once on

the Provider Services page, click on “Provider Forms Search” in the center of the page.

On the page that generates, select “Long Term Care Facility and Home Based Services”

in the “Type” dropdown box, while selecting “Hospice” in the “Category” dropdown box.

Finally, click the “Search” button at the bottom. The current versions of all DMAS hospice

forms will populate on the next page.

The provider must not alter any DMAS forms, though the forms may be duplicated. Forms

may also be obtained through Commonwealth Martin at 804-780-0076.

NOTE: These forms and processes may be different for providers who participate in the

Cardinal Care network. Refer to your provider contract or guidance from the MCO for

compliance audit specifications.