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PATIENT’S NAME_______________________________________
HOSPICE OF WARREN COUNTY
2 CRESCENT PARK WEST
WARREN, PA 16365
PROVIDER NO. 39-1551
MEDICARE HOSPICE BENEFIT REVOCATION
As a Medicare Hospice beneficiary, I wish to revoke the election of Medicare coverage of hospice care for the remainder of benefit period #__________.
I understand that I am forfeiting the right to __________ days of hospice coverage in the current benefit period. Should I choose to re-elect the Medicare Hospice benefit at a later time, I retain the right to use __________ days in benefit period #__________, and, if applicable, unlimited 60 day benefit periods.
THE BENEFIT PERIODS ARE AS FOLLOWS:
FIRST BENEFIT PERIOD – 90 DAYS
SECOND BENEFIT PERIOD – 90 DAYS
UNLIMITED 60 DAYS
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I DIRECT THIS REVOCATION TO BE EFFECTIVE ON __________ ___________
DATE TIME am / pm
I UNDERSTAND THAT THE MEDICARE HEALTH CARE BENEFITS WHICH I WAIVED TO RECEIVE HOSPICE MEDICARE COVERAGE WILL BE RESUMED ON THE ABOVE DESIGNATED DATE.
_____________________________________________ ______________
SIGNATURE OF BENEFICIARY OR LEGAL REPRESENTATIVE DATE
_____________________________________________
RELATIONSHIP OF LEGAL REPRESENTATIVE TO BENEFICIARY
____________________________________________ _ ______________
WITNESS SIGNATURE DATE
*** Hospice Revocation cannot be effective prior to the date this form is signed. A beneficiary may designate the effective date to be the same date as the signature date or a date in the future.
Revised 07/11/11
