Hospice Form Step 1 of 4 25% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Name* First Last Error Message Hospice Agency InformationHospice Agency NPI* 10 digitsHospice Agency Name* Error Message Agency Phone #*Agency Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationOrdering MD* Ordering MD Phone #*Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890HCPC/CPT Code (Click + or - at the right to add up to 5 Codes)*Code TypeCode Example HCPC code: S1234 with modifier: S1234 U1 Example CPT code: 12345Place of Service*Place of Service *Hospital InpatientSNFPhilip HulitarName of Facility* List all Durable Medical Equipment(provided under Hospice Benefit) Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentPer EOHHS, Neighborhood cannot pay for services provided by individuals legally responsible for the memberSignature of Treating Provider*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA