Form DOM-1166 A Hospice Revocation / Discharge Form - Mississippi

Form DOM-1166 A Hospice Revocation / Discharge Form - Mississippi

What Is Form DOM-1166 A?

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.

FAQ

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.

ADVERTISEMENT

Form Details:

  • Released on April 1, 2022;
  • The latest edition provided by the Mississippi Division of Medicaid;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

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.

Download Form DOM-1166 A Hospice Revocation / Discharge Form - Mississippi

4.6 of 5 (20 votes)
  • Form DOM-1166 A Hospice Revocation / Discharge Form - Mississippi, Page 1
ADVERTISEMENT