Forms and Processes (Attestation & NOE)

What is the difference between the DHCS 8052 Notice of Election (NOE) form and the new Online Medi-Cal Hospice Program Attestation Form?

The two forms serve different but related purposes in the Medi-Cal hospice election process:

• DHCS 8052 – Hospice Notice of Election (NOE) Form– Documents the Medi-Cal Fee-for-Service (FFS) member’s election of hospice services and captures their informed consent and original signature (or that of their legal guardian/authorized representative). Must be completed by Qualified Hospice Personnel (QHP) after counseling the member. Retained in the member’s medical record; not submitted to DHCS. Must be available upon DHCS request or during state/federal audits.
• Medi-Cal Hospice Program Attestation Form- Serves as the official notification to DHCS that the member has elected hospice services. Completed online by the hospice provider within five (5) calendar days of the election date. Provider attests that all requirements were met, including obtaining informed consent using DHCS 8052. Required starting March 2026; emailed or paper submissions will no longer be accepted.

Who can sign the Medi-Cal Hospice Program Attestation Form? 

Only Qualified Hospice Personnel (QHP) as defined in HSC Section 1746.50 (e.g., physicians, RNs, LVNs, medical social workers, chaplains, counselors).

Can office staff complete the form if the QHP is unavailable? 

Yes, but the QHP must sign the form.

Does the same QHP need to sign both the Attestation Form and the NOE Form? 

DHCS recommends the same QHP sign both, but any QHP may sign the Attestation Form.

Can the Attestation Form be signed by an RN or LVN? 

Yes. Both are considered QHPs.

What is the time frame for submitting the Attestation Form? 

Within five (5) calendar days of the member’s hospice election.

Can the Attestation Form be updated after submission? 

No. A new form must be submitted if corrections are needed.

Will providers receive confirmation after submitting the Attestation Form? 

Yes. A confirmation email will be sent. Providers should verify the 900 code in MEDS.

What if the member revokes hospice or transfers? 

Notify DHCS for FFS members via email to MCHospiceClerk@dhcs.ca.gov. MCP members require direct notification to the plan.

What is the ‘5-Day Rule’ for the Hospice Program Attestation Form? 

Submit form within five calendar days of hospice election (FFS to DHCS, MCP to the plan).

Are there exceptions to the 5-day rule? 

Yes. Exceptions include natural disasters, technical failures, newly certified providers, and retroactive eligibility.

Can the online Hospice Program Attestation Form be saved and completed later? 

No. It must be completed in one session.

Will providers receive confirmation after submitting the Hospice Program Attestation Form? 

Yes. An email confirmation will be sent.

What happens if incorrect information is submitted? 

Errors may trigger automatic rejection or require resubmission.

Are Hospice Program Attestation Forms required for dual-eligible members? 

Yes. Even if Medi-Cal is secondary, a valid form is required.

What if the member is retroactively approved for Medi-Cal? 

Contact the Hospice Clerk and provide proof of retroactive eligibility.

Is a placeholder diagnosis code acceptable? 

No. A valid diagnosis code and physician certification are required.

Is a new Medi-Cal Hospice Program Attestation Form required when a Medi-Cal member transitions from a Medi-Cal Managed Care Plan (MCP) to  Medi-Cal Fee-For-Service (FFS)?

Yes. A new Medi-Cal Hospice Program Attestation is required each time a member transitions to Medi-Cal FFS.

If the five (5) calendar day submission window for the Medi-Cal Hospice Program Attestation Form is missed, can it still be submitted to DHCS?

Yes, a Medi-Cal Hospice Program Attestation Form can be submitted after the five (5) calendar day period; however, Medi-Cal will not cover or reimburse for the days of hospice services that are provided between the hospice admission date and the date the Medi-Cal Hospice Program Attestation Form is submitted untimely to, and approved by, DHCS. These days will be considered a hospice provider liability, and hospice providers may not bill DHCS or the Medi-Cal FFS member for these days.  

Does submission of a Medicare Hospice Election Statement for dually eligible Medi-Cal members satisfy Medi-Cal’s policy requirements?

No. For dually eligible Medi-Cal members, hospice providers must submit a Medi-Cal Hospice Program Attestation Form and maintain a Medi-Cal NOE (DHCS 8052) on file in order to satisfy Medi-Cal policy requirements.

Once Medi-Cal’s new utilization management controls, including TAR requirements, are implemented, is submission of the Medi-Cal Hospice Program Attestation Form and maintenance of a Medi-Cal NOE (DHCS 8052) in a Medi-Cal member’s medical record still required?

Yes. TARs do not replace these requirements.