Also Known As:
Hospice consent form, hospice admission form, Medicare hospice election statement, MBI election form
Type:
Legal and administrative hospice document
Primary Purpose:
To formally enroll the patient in hospice and notify Medicare, Medicaid, or private insurance that the patient is electing the hospice benefit.
When It Applies:
Signed at admission, before routine hospice care can begin to be billed.
Who Is Involved:
The patient (or their legally authorized decision-maker), the admitting hospice nurse, and a witness.
Where It Occurs:
At the admission visit, usually at home, in a facility, or at the hospital bedside.
Duration:
Effective from the signature date until the patient is discharged, revokes hospice, or no longer meets eligibility.
Coverage:
Filing the form triggers Medicare/Medicaid/private-insurance coverage of all hospice services at no out-of-pocket cost.
Key Focus:
Patient understanding of what hospice covers (and what it replaces), the patient’s choice of provider, and the patient’s right to revoke at any time.
Common Misunderstanding:
Signing the election form does not waive other Medicare benefits unrelated to the terminal diagnosis. Only treatments aimed at curing the terminal illness are replaced by the hospice benefit.
What the Election Form Actually Commits To
The hospice election form is the document that formally begins care under the Medicare Hospice Benefit. By signing, the patient is making three statements:
- I understand my illness is terminal and I am choosing comfort-focused care
- I am choosing this specific hospice provider
- I understand the hospice benefit replaces Medicare’s usual coverage of treatments aimed at curing the terminal illness
That third point is the one families ask about most. The election form does not waive your Medicare coverage for unrelated conditions, a broken arm, a UTI in someone with cancer, an unrelated heart event in someone in hospice for Alzheimer’s. Those remain covered.
Revoking the Election
Election is fully reversible. A patient or their authorized decision-maker can revoke hospice at any time, return to curative treatment, and re-elect later if the situation changes. The Lifted team has helped many families revoke, take a few weeks to think, and either return to us or choose another path. The form is a step, not a contract.
If the patient revokes hospice, the Medicare Hospice Benefit simply pauses. Standard Medicare resumes coverage of curative care.
Who Signs When the Patient Can’t
If the patient lacks decision-making capacity, common in late-stage Alzheimer’s, advanced dementia, or after a significant stroke, the form can be signed by a legally authorized decision-maker. That is usually:
- The patient’s healthcare power of attorney
- A court-appointed guardian
- Under Texas surrogate consent rules, the next-of-kin in a defined order (spouse, then adult children, then parents, then adult siblings)
The Lifted admitting nurse can walk your family through this step. Start care or contact us with questions.