Who may sign this statement?

The patient signs when able. If incapacitated, an authorized representative with documented authority signs; include relationship and legal basis for authority in the signature block.

Can the election be changed or revoked?

Yes. The patient or representative may revoke the election at any time; document the revocation in writing and notify the hospice provider to stop hospice billing.

Is notarization required?

Most hospice elections do not require notarization, but state or facility policies can differ. When notary or witnesses are required, follow local rules before submission.

What if the Medicare number is wrong?

Incorrect beneficiary numbers can delay or reject claims. Correct records promptly and resubmit claims with corrected identifiers.

How should digital signatures be handled?

Use an e-signature solution that documents signer identity, timestamp, and audit trail. Ensure consumer-facing disclosures and retention meet ESIGN/UETA where applicable.

Where to store the completed form?

File the statement in the patient’s medical record, keep a billing copy, and retain an accessible electronic record per HIPAA and facility retention policies.

Electronic Signature
Templates
Healthcare
Healthcare Hospice Election Statement

Healthcare Hospice Election Statement

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE HOSPICE ELECTION STATEMENT

This Hospice Election Statement documents the voluntary election to receive hospice care and the associated acknowledgements and authorizations. Patient Name: Date of Birth: Medical Record/ID Number:

Patient Information

Full legal name Date of birth Gender Address Primary telephone Emergency contact (name, relation, phone)

Insurance / Payer Information

Primary insurance provider

Policy number

Group number

Subscriber / Insured name

Coverage indicators (check all that apply) Medicare hospice benefit Medicaid Private insurance Self-pay

Medical / Clinical Information

Primary terminal diagnosis Prognosis (anticipated life expectancy) Current medications Allergies / adverse reactions Relevant medical history / prior surgeries

Hospice Election

I hereby elect to receive hospice care from Hospice Provider: with an election effective date of .

I understand that the hospice benefit focuses on palliative care, comfort, and symptom management for the terminal illness and related conditions rather than curative treatment directed at the underlying terminal condition. I have been informed of the nature and scope of hospice services, including but not limited to nursing care, symptom control, counseling, and short-term inpatient care when clinically appropriate.

Level(s) of hospice care elected (check all that apply) Routine home care Continuous home care General inpatient care Respite care

I acknowledge that certain treatments intended to cure the terminal illness may be discontinued as part of hospice care. I understand that treatments unrelated to the terminal illness may continue if agreed upon in the plan of care. I have had the opportunity to discuss alternatives to hospice care, including continued curative treatment and other services.

Rights, Revocation, and Acknowledgements

I understand that I retain the right to revoke this hospice election at any time. To revoke this election I must notify the hospice provider in writing or verbally; revocation will be effective when received by the hospice provider unless a later effective date is specified. I further understand that revocation may result in termination of hospice-covered services and potential changes in coverage under my insurance.

I have been informed of my right to receive reasonable pain management and palliative care, and my right to participate in the development and review of the hospice plan of care. I retain the right to request transfer to another provider of hospice services and the right to file complaints regarding the quality of care.

Acknowledgement I acknowledge I have received an explanation of hospice services, my rights, and how to revoke this election.

If revoked, preference for written notice destination (name/address/phone)

Authorization to Use and Disclose Health Information

I authorize the release of medical information necessary for the provision and coordination of hospice care, payment, and healthcare operations. This authorization includes information concerning diagnosis, treatment, and medication relevant to hospice services. This authorization remains in effect until or until revoked in writing.

Release for coordination of care I authorize release of medical information to hospice interdisciplinary team and to other providers involved in my care.

Additional Notes / Patient Directives

Advance directive / POLST / other instructions Additional clinical or social considerations relevant to hospice care

Patient Name:

Signature:

Date:

If signed by authorized representative, state relationship:

If signed by representative, legal authority/capacity (e.g., health care proxy, guardian):

What the Healthcare Hospice Election Statement Is

A Healthcare Hospice Election Statement is a written declaration by a patient (or authorized representative) electing hospice care and waiving certain Medicare-covered curative treatments for the same terminal condition. It documents patient choice, identifies the hospice provider, states the election effective date, and records acknowledgements required by the hospice program. The form creates a record used by clinical staff, billing, and compliance teams to confirm service eligibility and coordinate Medicare hospice benefit claims. It is not a substitute for advance directives or power-of-attorney instruments.

Why this Statement Matters for Care, Coverage, and Compliance

The hospice election formalizes patient consent to hospice services and aligns clinical care, billing, and Medicare benefit rules. It provides evidence of informed choice, starts coverage coordination, and reduces later disputes about services or payment responsibility.

Step-by-step: Completing the Hospice Election Statement

Complete these steps in order to create a valid, auditable election record that supports care and reimbursement workflows.

01

Prepare Information: Gather patient ID, Medicare number, physician details, and provider info.
02

Enter Election Details: Record effective date, diagnoses, and scope of hospice services.
03

Obtain Signature: Patient or authorized rep signs and dates the statement.
04

File and Route: Send to hospice medical record, billing, and payer as required.

Common Questions and Quick Answers

Answers to frequently asked questions about validity, signatures, and correcting common errors on the Hospice Election Statement.

Need help? Contact support

Who may sign this statement?
The patient signs when able. If incapacitated, an authorized representative with documented authority signs; include relationship and legal basis for authority in the signature block.
Can the election be changed or revoked?
Yes. The patient or representative may revoke the election at any time; document the revocation in writing and notify the hospice provider to stop hospice billing.
Is notarization required?
Most hospice elections do not require notarization, but state or facility policies can differ. When notary or witnesses are required, follow local rules before submission.
What if the Medicare number is wrong?
Incorrect beneficiary numbers can delay or reject claims. Correct records promptly and resubmit claims with corrected identifiers.
How should digital signatures be handled?
Use an e-signature solution that documents signer identity, timestamp, and audit trail. Ensure consumer-facing disclosures and retention meet ESIGN/UETA where applicable.
Where to store the completed form?
File the statement in the patient’s medical record, keep a billing copy, and retain an accessible electronic record per HIPAA and facility retention policies.

Who typically completes and uses this document

Each role has a specific responsibility: capture accurate data initially, confirm clinical appropriateness, and retain records for compliance and billing.

Hospice intake staff who gather patient demographics and eligibility information for enrollment.
Clinical teams (nurses, physicians) who verify diagnosis, prognosis, and document medical necessity.
Billing and compliance teams who use the form to submit Medicare hospice claims and maintain audit records.

Primary signers and document stakeholders

Hospice Administrator

Responsible for ensuring forms meet program requirements, maintaining provider identifiers, and coordinating with billing and compliance teams. They verify that election documents are complete, stored in the medical record, and forwarded to payers as needed for reimbursement and audit readiness.

Authorized Representative

A family member or legally appointed agent who signs when the patient is incapacitated. They must provide documentation of authority and relationship, and their signature will be used to establish consent and direct hospice care.

Essential data points to capture on the form

Patient Name: Full legal name

Beneficiary ID: Medicare MBI or HICN

Effective Date: MM/DD/YYYY

Provider ID: Hospice Medicare number

Attending Physician: Name and contact

Signature Details: Signer, date, authority

Risks and consequences of incomplete or incorrect statements

Claim Denial: Lost reimbursement

Compliance Finding: Audit exposure

Billing Delays: Cashflow impacts

Privacy Breach: HIPAA penalties

Invalid Election: Care coordination gaps

Legal Challenge: Potential disputes

Common preparation errors to avoid

Entering an incorrect Medicare number or misspelling the beneficiary’s legal name, which frequently causes claim rejections and delays.
Failing to document the authorized representative’s authority or relationship, leading to later disputes about the validity of consent.
Using an unclear effective date format or leaving the effective date blank, creating ambiguity about when coverage and billing should begin.
Not retaining a signed copy in the medical record and billing files, which impedes audits and compliance reviews.

Core elements included in a professional Hospice Election Statement

A complete statement groups clinical, administrative, and legal elements so care, billing, and compliance teams can act without additional follow-up.

Identification

Patient identifiers, Medicare beneficiary number, date of birth, and contact details that ensure accurate matching in clinical and claims systems.

Provider Information

Hospice legal name, Medicare provider number, address, and intake contact used to route clinical inquiries and billing submissions.

Clinical Basis

Primary diagnosis, prognosis comments, and attending physician attestation documenting medical necessity for hospice services.

Election Details

Effective date, scope of hospice services elected, any concurrent treatments agreed upon, and limitations or conditions noted at election.

Consent and Signature

Patient or authorized representative signature, printed name, relationship, authority documentation, and signature date to evidence informed consent.

Routing and Retention

Instructions for internal routing to medical record, billing, and compliance plus retention guidance to meet HIPAA and program requirements.

Where to send and how the form is processed

After signing, the statement should be routed promptly to clinical records, billing, and the payer as required for coverage and claims.

Medical Record: File the signed statement in the patient’s permanent chart.
Billing Office: Send a copy to claims staff to begin hospice billing.
Payer Notification: Notify Medicare or commercial payers per payer rules.
Compliance Archive: Retain an accessible electronic copy for audits.

Customizing online workflows for hospice election processing

Configure these workflow settings to automate routing, authentication, and record retention for signed election statements.

Field Validation Rules	Require MBI format and MM/DD/YYYY date
Signer Authentication	Email or SMS OTP for identity confirmation
Automatic Routing	Send signed copy to records and billing
Template Management	Use a locked template to preserve required fields
Audit Trail Capture	Record IP, timestamp, and signer events

Technical and security considerations for eSigning

Confirm the vendor supports HIPAA BAA, robust access controls, and retains tamper-evident audit logs to meet regulatory and payer requirements.

Encryption: TLS 1.2/1.3 in transit
Data at Rest: AES-256 encryption
Integrations: Connects with EHR and billing

Timing and processing expectations to keep in mind

Key dates and turnaround expectations ensure timely coverage, claims submission, and accurate medical recordkeeping.

Election Effective Date:

Date entered determines when hospice benefits may begin

Provider Acknowledgement:

Hospice typically documents acceptance within days of intake

Claim Submission Window:

Submit claims per payer billing deadlines to avoid denials

Revocation Notice:

Document revocations immediately upon patient direction

Record Availability:

Maintain signed copy accessible for audits and appeals

Key milestones from election to claims

A typical lifecycle moves from election signing through provider processing to claims submission and potential revocation.

01

Election Signed

Patient or representative executes the election form.

02

Intake Processed

Clinical team verifies eligibility and enters the record.

03

Coverage Effective

Billing begins as of the effective date if criteria met.

04

Claims Submitted

Claims are submitted according to payer schedules and rules.

How the Hospice Election Statement compares with nearby documents

Compare this form against related instruments to determine purpose, revocability, and witness requirements.

Document Type	Hospice Election	Advance Directive
Purpose	elect hospice care	specify future treatment wishes
Revocable
Typical Witnesses	varies by state	often 2 witnesses
Primary Use	start hospice services	guide end-of-life decisions

eSignature vendor comparison for executing Hospice Election Statements

Pricing and feature snapshot to compare baseline plans and capabilities for secure signing and PHI handling. No data-date references are included here.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Free trial available	Free trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Illustrative scenarios showing typical use

Two practical examples demonstrate common hospice election workflows and outcomes in clinical settings.

Case Study 1

A hospice intake nurse completes the election during a home visit to record patient consent and start care.

The intake nurse documents the physician and effective date.
The timely, complete form enabled the hospice to begin services immediately and submit claims without follow-up, reducing administrative delays and improving patient support continuity.

Case Study 2

An authorized representative signs on behalf of an incapacitated patient after presenting power-of-attorney documentation.

Documentation of authority is attached to the election.
Having the representative’s authority and a fully completed statement on file avoided billing disputes and ensured clear communication between the hospice, hospital, and payer.

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