HCA 13-746 (12/16)
HCA/Medicaid Hospice Notification
FAX 360-725-1965 (notification)
For verification of hospice dates, please check the ProviderOne website at
https://www.waproviderone.org
Please fill out the form electronically, then print the form and fax to 360-725-1965.
ACES CLIENT ID NUMBER CLIENT NAME (LAST, FIRST, MI)
CLIENT DATE OF BIRTH SOCIAL SECURITY NUMBER
HOSPICE NPI NUMBER HOSPICE CONTACT HOSPICE TELEPHONE NUMBER HOSPICE FAX NUMBER
PROVIDERONE PROVIDER NUMBER PROVIDERONE CLIENT ID
Name and mailing address of hospice agency:
Election/hospice begin date Hospice end date Reason for end date
Deceased Discharged Revoked
Provider NPI
Physician or Dx
change date
Physician name
Diagnosis
code
Description of Dx code
A.
From:
To:
B.
From:
To:
C.
From:
To:
Total monthly hospice rate (cost of care)
anticipated
Late notification, give reason:
Date of notification letter/
communication
Date application sent Date Release of Information
Faxed
Medicare primary
Place of service (choose one) Name and physical address
Dates of residence
From To
Home
Nursing home
Hospice care center (145) or (656)
In-patient hospital (656)
If the client is currently in a nursing home, hospice care center or hospital, and wishes to return home, does a medical provider
certify that it will likely happen within six months?
Yes No
Does the client need a monthly home maintenance allowance as a participation deduction? Yes No
Comments:
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