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Form 165 Medicaid Hospice Election and Physician's Certification - Alabama
What Is Form 165?
This is a legal form that was released by the Alabama Medicaid Agency - a government authority operating within Alabama. Check the official instructions before completing and submitting the form.
FAQ
Q: What is Form 165?
A: Form 165 is the Medicaid Hospice Election and Physician's Certification form.
Q: What is Medicaid Hospice?
A: Medicaid Hospice is a program that provides end-of-life care to eligible individuals.
Q: Who is eligible for Medicaid Hospice?
A: Eligibility for Medicaid Hospice varies by state and is based on certain criteria, such as having a terminal illness and a life expectancy of six months or less.
Q: What is the purpose of Form 165?
A: Form 165 is used to elect Medicaid Hospice care and certify that a patient meets the eligibility requirements.
Q: Who needs to complete Form 165?
A: Form 165 must be completed by the patient's attending physician and signed by both the physician and the patient (or the patient's legal representative).
Q: What information is required on Form 165?
A: Form 165 requires information about the patient's medical condition, the physician's certification of the patient's eligibility, and the patient's choice to elect Medicaid Hospice.
Q: When should Form 165 be submitted?
A: Form 165 should be submitted to the Alabama Medicaid Agency before or within five days of the start of hospice care.
Q: Are there any fees associated with Medicaid Hospice?
A: No, Medicaid Hospice is a covered benefit and does not require any fees from eligible individuals.
Q: Can I make changes to my Medicaid Hospice election?
A: Yes, you can revoke or change your Medicaid Hospice election at any time by submitting a new Form 165.
Form Details:
- Released on July 1, 2013;
- The latest edition provided by the Alabama Medicaid Agency;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form 165 by clicking the link below or browse more documents and templates provided by the Alabama Medicaid Agency.
