Hospice Election Statement Addendum (Non-Covered Items, Services, or Drugs)

Patient Notification of Hospice Non-Covered Items, Services, and Drugs

Hospice: [Hospice name, full mailing address, phone number]

Patient: [Patient full legal name]

Medical record number (MRN): [MRN]

Date of birth: [Date of birth]

Addendum status: [Initial / Update]

Version number: [Version or update number]

Effective date: [Effective date]

Prior addendum superseded: [Prior addendum date and version] (Include only if status is Update)

Request and Furnishing Details

Requested by: [Patient / Patient representative: [name, relationship] / Non-hospice provider: [entity name] / Medicare contractor: [contractor name]]

Request date: [Request date]

Date furnished: [Date furnished] (Required; do not leave blank)

Method furnished: [In person / Mail / Secure email or portal / Other: [specify]]

Terminal Illness and Related Conditions

Terminal diagnosis: [Plain-language description of terminal illness] ([Clinical term])

Major related conditions contributing to symptom burden or prognosis:

• [Related condition 1]
• [Related condition 2]
• [Related condition 3]

(Include only conditions explicitly documented; this list need not be exhaustive)

Non-Covered Conditions, Items, Services, and Drugs

Condition/Diagnosis Determined Unrelated	Items, Services, or Drugs Not Covered by Hospice	Plain-Language Explanation	Reference
[Unrelated condition/diagnosis]	[Service: [type], [setting]] [Drug: [name], [route]] [Item: [DME/supply category]] (If specific items/services not yet identified: "Specific non-hospice items/services for this condition are not yet identified as of [date furnished]; this addendum will be updated if this changes.")	[Short, plain-language explanation of why this condition is not caused by or part of the terminal illness and why the listed items/services/drugs are not needed to manage pain or symptoms of the terminal illness] (Use brief sentences; define medical terms)	[Ref 1]

(Add additional rows as needed for each unrelated condition)

(If no unrelated conditions or non-covered items have been identified, include instead: "At this time, the hospice has not identified any conditions, items, services, or drugs that are unrelated to the terminal illness and related conditions.")

References

1. [Ref 1: [Hospice policy name, version/date] / [Clinical practice guideline, organization, year] / [Medicare coverage guidance, section, date]]
2. [Ref 2: [Source]]

(If no external guideline applies: "Determination based on patient-specific clinical assessment and hospice policy [Policy Name/Version].")

Purpose and Right to Advocacy

Purpose: This addendum notifies you in writing which conditions, items, services, and drugs the hospice will not cover because they have been determined unrelated to your terminal illness and related conditions. Decisions about whether something is related are made for each patient individually. Please share this document with other health care providers if you seek care for conditions not related to your hospice diagnosis.

Right to Immediate Advocacy: If you disagree with the hospice's determination, you have the right to immediate advocacy through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Contact: [BFCC-QIO name], [Phone], [Website].

Signature and Receipt Acknowledgment

Signing this addendum acknowledges receipt only; it does not indicate agreement with the hospice's determinations.

Patient signature: ____________________________ Date: [Date]

Patient printed name: [Patient full legal name]

Representative signature: ____________________________ Date: [Date] (Include when applicable)

Representative printed name: [Representative name] Relationship: [Relationship]

If signature was not obtained, document one reason:

• Refused to sign: [Reason provided, if any]
• Unable to sign: [Reason] [How receipt was otherwise acknowledged]
• Patient died before signing: [Details]
• Patient revoked hospice before signing: [Details]
• Patient discharged before signing: [Details]

(The reason for missing signature must be documented on this addendum)