Frequently Asked Questions for the Hospice Election Form and Addendum
Hospice Election and Addendum forms are required from
each Medi-Cal beneficiary, or their legal representative who elect hospice
services. It is the responsibility of the Hospice agency to fully complete and electronically
submit the forms, with the appropriate signatures, to DHCS no later than five
days after the election of hospice services.
Are hospice providers required to submit the hospice election form electronically?
Yes, to access the Hospice Program, you can:
Attn: DHCS Hospice Clerk
Department of Health Care Services
Medi-Cal Eligibility Division, MS 4607
1501 Capitol Avenue
P.O. Box 997417-7417
Sacramento, CA 95899-7417
Are hospice providers required to submit Hospice Election and Addendum forms electronically?
A: Yes. Send via E-mail to: MCHospiceClerk@DHCS.ca.gov
Where can I find the required electronic Hospice Election and Addendum forms?
Both forms can be found on the DHCS website. The PDF forms can be downloaded and are compatible with Electronic Medical Record (EMR) systems. The PDF forms are also compatible with DocuSign for initials, signatures, and submissions of the completed forms via e-mail.
If the hospice agency cannot fill out the forms electronically what can be done?
The Hospice Election and Addendum forms can be downloaded from the DHCS Hospice Program website, DHCS Hospice Program website. Forms can be filled out manually, scanned and sent by e-mail or postal mail.
How are providers notified of receipt of the Hospice Election and Addendum forms?
The Hospice Clerk will send a notification in the same manner the forms were received as soon as the completed forms are reviewed and accepted.
What If the Hospice Election or Addendum forms are rejected?
The Hospice Clerk will notify the Hospice agency of the necessary corrections as soon as possible. The Hospice provider must resubmit the updated forms within five business days of the original election of hospice services.
Where can I find the DHCS Hospice Program contact information?
The DHCS Hospice Program web page has contacts, resources, and the latest updates. You can email your questions to MCHospiceClerk@DHCS.ca.gov or call (916) 552-9200.
Do Hospice providers follow the same procedures when enrolling Managed Care Plan members?
No. Hospice providers should follow the specific enrollment and documentation procedures established by each Managed Care Plan (MCP), as these requirements may vary from plan to plan. The DHCS 8052 Hospice Election Form and the Addendum Form are only required to be submitted to DHCS for Fee-for-Service (FFS) members.
For MCP members, providers should retain the completed forms in the patient’s medical record and coordinate directly with the plan to ensure compliance with its specific processes.
