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Hospice Notification Form Available Online

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

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