Hospice Medical Authorization Form

Medical Authorization Form

This form is to be completed by a Hospice Representative ONLY
As a reminder, the patient application will remain pending until we receive this signed Medical Authorization and supporting documentation.
Patient Name*

First NameLast Name
Patient's Terminal Diagnosis*
Date of Diagnosis*

MonthDayYear
Date
Date of Admission*

MonthDayYear
Date
Current Life Expectancy in Months*
Name of Treatment Facility/Hospital that referred the patient for hospice services*
Name of Hospice Representative*

First NameLast Name
Name of Hospice Company*
Hospice Company Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Office Phone Number*

Area CodePhone Number
Cellphone Number*

Area CodePhone Number
Email Address*
example@example.com
Please upload FACE Sheet*

Browse Files

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Message to the Hospice Representative: We always operate by having an initial conversation with the hospice representative after a completed application has been submitted and reviewed. We may have more questions that need answering to understand the need and what was assessed in the home ﬁrsthand. We never do this in an intrusive manner and do our best to be sensitive to the family’s situation during this emotional and stressful time. We seek to foster a partnership with you to help better serve your patients. We rely heavily on your honesty and professional opinion about the patient’s request and how we can best help them.
I certify that I am the assigned Hospice Representative of the patient and acknowledge to the best of my ability that my patient has a life expectancy of six months or less. I conﬁrm that all information provided above is accurate. I have read and understand the statement above and will do my best to partner with Project 4031 to provide any required additional information dependent on the request. I have discussed Project 4031’s service capabilities with my patient and have deemed the request to be reasonable. I recognize that dependent on the request, there are potential risks involved. I have discussed these possible risks and informed my patient that they will assume the full liability of all injuries, damages, or loss, regardless of severity that they may sustain as a result of said participation. To the best of my knowledge I believe my patient is an eligible candidate for assistance and I believe it will improve their quality of life.
Signature of Hospice Representative*

Clear
Title of Signer*
Date of Signing*
Should be Empty: