Medical Benefit Election | Hospice of Warren County

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PATIENT’S NAME: __________________________________

ADDRESS _________________________________________

HOSPICE OF WARREN COUNTY
2 CRESCENT PARK WEST
WARREN, PA 16365
PROVIDER NO. 39-1551

ELECTION OF HOSPICE MEDICARE BENEFIT – INFORMED CONSENT

I ACKNOWLEDGE/UNDERSTAND THE FOLLOWING:

I understand the nature of the hospice care available through the Hospice
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 ____________________________________________________.

I understand there will be a hospice team providing care for me, composed
of a physician, nurse, social worker, pastoral counselor, volunteer, and other
disciplines that may be necessary.

I waive the right to all other benefits under the Medicare Program while
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.

Medicare will make payment for unlimited hospice days. However, the
days are broken into benefit periods to be used in this order. These periods
are as follows:

First Benefit period – 90 days
Second Benefit Period – 90 days
Unlimited – 60 days

I understand that I can use standard Medicare in the usual manner to
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

MOS-5055-OS