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.