Free 48733.PDF - Indiana


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Date: January 16, 2003
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State: Indiana
Category: Government
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HOSPICE PROVIDER CHANGE REQUEST BETWEEN INDIANA HOSPICE PROVIDERS
State Form 48733 (R / 12-02) / OMPP 0009

The information contained on this completed form is CONFIDENTIAL according to 405 IAC 1-16, 5-2-10.1, 5-2-10.2, 5-5-1, and 5-34.

A. PROVIDER CHANGE REQUEST EFFECTIVE DATE OF CHANGE:

FIRST BENEFIT PERIOD SECOND BENEFIT PERIOD

THIRD BENEFIT PERIOD

B. RECIPIENT INFORMATION
Name of recipient (last, first, middle initial) Recipient's Social Security number

Primary hospice diagnosis (ICD-#):

Recipient's Medicaid number

THE ABOVE NAMED RECIPIENT REQUESTS THAT THE DESIGNATION OF HIS / HER HOSPICE BE CHANGED FROM (completed by sending hospice):

C. PROVIDER LEAVING
Name of Hospice Provider Hospice Medicaid Provider number

Signature of Provider RN

Hospice telephone number

Name of Attending Physician

Physician Medicaid Provider number

TO THE FOLLOWING HOSPICE PROVIDER (completed by receiving hospice):

C. PROVIDER ENTERING
Name of Hospice Provider Hospice Medicaid Provider number

Signature of Provider RN

Hospice telephone number

Name of Attending Physician

Physician Medicaid Provider number

As a hospice recipient, I understand that this change in hospice providers is not a revocation of the remainder of my current election benefit period.

E. Signature of recipient or representative

Signature of witness

Date

NOTES:

(1) Patient must be accepted for transfer by the new provider prior to leaving current provider. (2) Each hospice must maintain a copy of the Provider Change Request. It is the responsibility of the receiving hospice to forward a completed copy to the Medicaid Prior Authorization Unit within 5 days of the effective date stipulated in Part A above. (3) A change of ownership is not considered a change in the patient's designation of a hospice and requires no recipient action.