A Hospice Notification Form is available online. This form is to be used when a recipient elects hospice and again when the recipient ends hospice services. The form meets the conditions per ARSD 67:16:36:06 and includes the following information:
- Hospice provider information including provider name, NPI, contact person and phone number,
- Recipient information including recipient name and South Dakota Medicaid ID,
- Date of election,
- ICD-10 Diagnosis,
- Notification if the recipient is in a nursing home,
- End of hospice service and
- Reason for end of election (revocation, death, discharge).
A hospice provider may choose to use a different notification form, but all information listed above must be included. All hospice notification forms can be sent via fax to:
Department of Social Services
Division of Economic Assistance
(605)773-7183
Questions about hospice may be directed to the Medicaid Telephone Service Unit, 1-800-452-7691
