Form Pro-117-D - Bcbs Request For Certification Form (Page 2 of 2) in pdf

Medications

(list all)

Name of Drug

Dosage

Covered by Hospice (Y/N)

____________________________________________________________________________________

Patient no longer seeking aggressive treatment for disease process, is desiring symptom

management and comfort care only:

Yes ____

No____

DNR signed and understood by patient and family:

Yes ____

No ____

Has patient received Home Health or Hospice services in the last 6 months?

Yes ____

No ____

If yes, name and telephone number of agency__________________________________________________

Other: _______________________________________________________________________________

_______________________________________________________________________________

Ordering MD (not Hospice Medical Director)

Name__________________________________________ Provider Number ________________________

Office Address _________________________________________________________________________

*Submit physician order for Hospice with request for certification*

*Attach clinical information*

*Attach supporting documentation*

Hospice Name and Contact _______________________________________________________________

Address ______________________________________________________________________________

FAX _____________________________

Telephone Number___________________________________

Tax ID Number _______________________________________________________ __________________

Name of Hospice Medical Director __________________________________________________________

You may FAX completed form to:

FEP Hospice Care Coordinator

at (205) 220-0859

PRO-117-D (Rev. 11-2015) back

Form Pro-117-D - Bcbs Request For Certification Form Page 2