Senior & Elder Care

Hospice Election & Informed Consent

Medicare Hospice Benefit election statement and informed consent, documenting the patient's voluntary election to waive curative treatment in favor of palliative comfort care, understanding of the six-month prognosis requirement, revocation rights, and covered versus non-covered services. Patient signer.

📄 1 signer📅 30-day expiry🏷 Senior & Elder Care🔖 single-signer, consent, senior-care, hospice, palliative-care, end-of-life, medicare, election-statement, waiver

About this template

The Hospice Election & Informed Consent is a ready-to-use senior & elder care template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, senior care, hospice, palliative care, end of life, medicare. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.

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# Hospice Election & Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Hospice Organization:** ___________ **Hospice Medical Director:** ___________ **Attending Physician (if different):** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medicare Beneficiary ID (MBI):** ___________ **Primary Diagnosis:** ___________ *Terminal illness with a prognosis of six months or less if the illness runs its normal course* **Election Effective Date:** ___________ **Initial Benefit Period:** ___________ --- ## 1. Medicare Hospice Benefit Overview The Medicare Hospice Benefit (42 C.F.R. Part 418; Social Security Act § 1861(dd)) provides comprehensive palliative and support services for Medicare beneficiaries with a terminal illness and a life expectancy of six months or fewer if the illness runs its normal course. By electing hospice, I understand the following: **(a) Two physicians must certify** that my terminal illness has a prognosis of six months or fewer if it runs its normal course. The certifying physicians are: **Certifying Physician 1:** ___________ **Certifying Physician 2:** ___________

Fields (23)

consent date
date · required
hospice name
text · required
medical director
text · required
attending physician
text
patient name
text · required
patient dob
date · required
medicare id
text
primary diagnosis
text · required
election effective date
date · required
benefit period
select · required
certifying physician 1
text · required
certifying physician 2
text · required
revocation contact
text · required
code status
select · required
advance directive status
select · required
grievance contact
text · required
primary caregiver name
text · required
caregiver relationship
text · required
care setting
select · required
care address
textarea · required
hipaa ack
checkbox · required
governing state
select · required
patient signer name
text · required

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Send this template with cryptographic proof

Every signed document gets PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package sealed in WORM storage.

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