HOSPICE OF WARREN COUNTY
2 CRESCENT PARK WEST
WARREN, PA 16365
PROVIDER NO. 39-1551
Medicare Benefit and am aware that all treatment will be palliative rather
than curative in nature. Treatment will be for management of symptoms
and to provide comfort for my terminal illness of ____________________________________________________.
of a physician, nurse, social worker, pastoral counselor, volunteer, and other
disciplines that may be necessary.
I am receiving hospice benefits. Only Hospice of Warren County will be
able to receive Medicare payment for care or service provided to me for
my terminal illness or any other condition related to my terminal illness.
days are broken into benefit periods to be used in this order. These periods
are as follows:
Second Benefit Period – 90 days
Unlimited – 60 days
pay the bill of:
1. My doctor, if he is not an employee of this Hospice.
2. Treatment of a condition unrelated to my terminal illness (see above)
I understand that I can revoke this benefit at any time and resume regular
Medicare coverage. I know I will lose any hospice days remaining in the
benefit period in which I revoke.
ACKNOWLEDGING/UNDERSTANDING THE ABOVE, I AUTHORIZE
HOSPICE MEDICARE COVERAGE TO BEGIN ON:
______________________________________ TIME: ___________
Month / Day / Year
Date of Signature Signature of Beneficiary or Legal Representative
Relationship of Legal Representative to Beneficiary
Date of Signature Witness Signature