This is a legal form that was released by the Mississippi Division of Medicaid - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.
Q: What is DOM-1166?
A: DOM-1166 is a Hospice Revocation/Discharge Form used in Mississippi.
Q: What is the purpose of DOM-1166?
A: The purpose of DOM-1166 is to revoke or discharge hospice services in Mississippi.
Q: Who should use DOM-1166?
A: DOM-1166 should be used by individuals who want to revoke or discharge hospice services in Mississippi.
Q: Is there a fee for using DOM-1166?
A: No, there is no fee for using DOM-1166.
Q: What information is required on DOM-1166?
A: DOM-1166 requires information such as the individual's name, Medicaid ID, date of revocation/discharge, and reason for revocation/discharge.
Q: What should I do after submitting DOM-1166?
A: After submitting DOM-1166, it is important to follow up with your hospice provider and the Mississippi Department of Medicaid to ensure that your revocation/discharge is processed.
Q: Can I change my mind after submitting DOM-1166?
A: It depends on the specific circumstances. It is recommended to consult with your hospice provider and the Mississippi Department of Medicaid if you wish to change your decision after submitting DOM-1166.
Q: Are there any specific guidelines for completing DOM-1166?
A: Yes, it is important to carefully read and follow the instructions provided on the form to ensure accurate and complete completion of DOM-1166.
Form Details:
Download a fillable version of Form DOM-1166 A by clicking the link below or browse more documents and templates provided by the Mississippi Division of Medicaid.