Hospice providers are required to include within the medical record a Medicaid Hospice Election and Physician’s Certification form (Form 165) that has been signed and dated by the physician. The exception to this is when an individual is eligible for Medicare as well as Medicaid. In that case, the Medicare election form will continue to serve as election for both hospice programs.

Form 165 was recently revised to include blanks to enter the Date of Benefit Period and the Date Physician Signed.  Effective September 1, 2013, all Hospice Providers should discard all copies of the previous Form 165 and utilize the revised form.

The revised Form 165 and the Instructions for Completion of Hospice Election Form 165 will be located on the Agency’s website, effective September 1, 2013, and can be accessed at the following:  Resources/Forms Library/Long Term Care/Form 165.

For questions or concerns regarding the Medicaid Hospice Program, please contact Felicha Fisher at (334) 353-5153.