Hospice Information For Medicare Part D - Gateway Health Plan Page 2

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HOSPICE INFORMATION for MEDICARE PART D
SECTION II – PLAN OF CARE (Optional)
Hospice Name
Hospice NPI
Patient Name
Patient ID# (HICN)
Patient DOB
/
/
Additional Medications Under Hospice Plan of Care and Designation of Financial Responsibility
Medication Name and Strength
Hospice
Patient
Medication Name and Strength
Hospice
Patient
Signature of Hospice Representative
Representative __________________________________________________________________________________ Date_____/______/________
Signature of Beneficiary or Beneficiary Authorized Representative
Beneficiary/Representative ________________________________________________________________________ Date_____/______/________
*This fax is intended for the use of the individual or entity to which it is addressed. It contains confidential information that is privileged and
exempt from disclosure under State and Federal law. If you are not the intended recipient, distribution or copying of this communication is strictly
prohibited.

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