Notification Hospice 2019-2026

The member signed the Member Election of Hospice Benefit form F-1009 on the date indicated below and has been certified by a physician as having six months or less life expectancy if the illness follows its usual course. DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1008 10/08 STATE OF WISCONSIN HFS 107. 31 2 b Wis. Admin. Code WISCONSIN MEDICAID NOTIFICATION OF HOSPICE BENEFIT ELECTION ForwardHealth requires certain information to enable the program to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full correct and truthful information for the submission of correct and complete claims for reimbursement. DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1008 10/08 STATE OF WISCONSIN HFS 107. 31 2 b Wis. Admin* Code WISCONSIN MEDICAID NOTIFICATION OF HOSPICE BENEFIT ELECTION ForwardHealth requires certain information to enable the program to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full correct and truthful information for the submission of correct and complete claims for reimbursement. This information should include but is not limited to information concerning enrollment status accurate name address and member identification number HFS 104. 02 4 Wis. Admin* Code. Under s. 49. 45 4 Wis. Stats. personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. This form is mandatory use an exact copy of this form* ForwardHealth will not accept alternate versions i*e* retyped or otherwise reformatted of this form* Hospice benefits are covered services for members enrolled in Wisconsin Medicaid or BadgerCare Plus. Instructions Type or print clearly. This form has two pages always complete Section I and any other sections of the form that apply to the member. When complete mail the form to ForwardHealth Member Services P. O. Box 6678 Madison WI 53716-0678. SECTION I COMPLETE FOR ALL HOSPICE MEMBERS The member named on this form has elected to receive Medicaid hospice benefits. The member s hospice has the Physician Certification/Recertification of Terminal Illness form F-1011 on file. Name Member First Middle Initial Last Member ID Date Election Form Signed Name Hospice Hospice s National Provider Identifier NPI Name Attending Physician Attending Physician s NPI Is the Attending Physician Employed by the Hospice Yes No The hospice and nursing home named below are in agreement that the hospice shall provide hospice services while the nursing home shall provide room and board services as defined under COBRA P. L* 99-272. Room and board includes the performance of personal care services including assistance in the activities of daily living socializing activities administration of medication maintaining the cleanliness of the resident s room and supervision and assistance in the use of durable medical equipment DME and prescribed therapies.