Fill and Sign the Hospice Nursing Home Interface P 00252 Wisconsin Department of Form

Print Clear Form DHS|OHA HOSPICE NOTIFICATION FOR NURSING FACILITY RESIDENTS HOSPICE PROVIDERS: When an Oregon Medicaid nursing facility resident elects hospice, please complete and submit this form via secure email to MMA.525@dhsoha.state.or.us within two business days of the hospice election. Also use this form to submit updates when the resident’s status changes. • Complete all fields; enter “N/A” if a field is not applicable. • By submitting this form, you attest to having a current, signed contract with the nursing facility. REASON FOR NOTIFICATION – Select one and give the effective date, if requested. Resident elected hospice. Hospice election date: Resident death. Date of death: Hospice discharged the resident (patient no longer meets hospice criteria). Discharge date: Resident revoked hospice. Revocation date: Resident transfer to new (select one): nursing facility (NF), hospice or address. Transfer date: Complete the Transfer Information section of this form to tell us about the resident’s new location. Other. Please explain: HOSPICE INFORMATION 1. Medicaid Provider #: 2. Contact Name and Telephone #: 3. Hospice Agency Name and Mailing Address: RESIDENT INFORMATION 4. Medicaid (Prime) ID #: 5. Name (Last, First, MI): 6. Date of Birth (MM/DD/YYYY): 7. NF Name: 9. NF Contact Name and Telephone #: 8. NF Provider # or NPI: 10. CCO Name: TRANSFER INFORMATION – Please complete this section for all resident transfers. 11. Provider Name 12. Provider # or NPI: 14. Contact Name and Telephone #: 16. Additional Information: 15. New Address (if not a transfer to new hospice or NF): APD/AAA/OHA USE ONLY 17. Date Received: 18. Date Entered in MMIS: OHP 525 (8/18)