"South Dakota Medicaid Hospice Notification" - South Dakota

South Dakota Medicaid Hospice Notification is a legal document that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota.

Form Details:

  • The latest edition currently provided by the South Dakota Department of Social Services;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.

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SOUTH DAKOTA MEDICAID
HOSPICE NOTIFICATION
This form must to be submitted within 5 working days of election/end
of hospice services per ARSD 67:16:36:06. Submit this form via fax to:
Department of Social Services
Division of Economic Assistance
(605)773-7183
Hospice Provider Information
Provider Name:
NPI:
Contact Person:
Phone Number:
Recipient Information
Recipient Name:
Recipient ID:
Election
Begin date of hospice:
ICD-10 diagnosis:
Is this recipient currently in a nursing home? ☐Yes
☐No
End
End date of hospice services:
Reason for end
☐Revocation
☐Death
☐Discharge
of services:
SOUTH DAKOTA MEDICAID
HOSPICE NOTIFICATION
This form must to be submitted within 5 working days of election/end
of hospice services per ARSD 67:16:36:06. Submit this form via fax to:
Department of Social Services
Division of Economic Assistance
(605)773-7183
Hospice Provider Information
Provider Name:
NPI:
Contact Person:
Phone Number:
Recipient Information
Recipient Name:
Recipient ID:
Election
Begin date of hospice:
ICD-10 diagnosis:
Is this recipient currently in a nursing home? ☐Yes
☐No
End
End date of hospice services:
Reason for end
☐Revocation
☐Death
☐Discharge
of services: