VT · guidance
Vt. Medicaid Hospice Provider Manual § 18
Forms
For forms and resources regarding how to report patient admissions, discharges, or changes, visit
Forms and Applications.
a. VT Choices for Care & Brain Injury Program 804 Change Report Form and process can be
located at the link above. This is for changes in care, settings, or services for members who
are on the CFC program. Includes admission to new services or termination of current
services.
b. General Inpatient Information
c. Certification Statement
d. Election Statement - make sure the form has the right content as in 20.2.1.1
e. Revocation Statement
f. Change of Hospice
g. Notification of death
h. Choices for Care Participant Admission to Hospice
i. 804B Nursing Home Change of Payment
Provenance
- Source
- www.vtmedicaid.com
- Retrieved
- 2026-10-01
- Edition
- hpm-2025-11-01
- Content hash
9ec32d72b612be727ca6a23087a04d77b292288eb4993b12ec71b27b03c170d0
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