Download Your Applicable Hospice Care Admission Forms
After you have had a conversation with a member of the Minnesota Hospice care team, please download the applicable consent/election documents listed below. Please note that part of obtaining your informed consent includes providing you with the following documents: Notice of Privacy Practices, Understanding Advance Directives and Patient Rights and Responsibilities. Please be sure you sign and date the Patient Consent for Care, Election of Hospice, Do Not Resuscitate (DNR) and Authorization to Release Health Information. In addition, be sure to indicate the date that hospice care will start (if different from the date you are signing). Also, include your choice for attending physician on the Election of Hospice form.
All admission forms should be faxed to Minnesota Hospice at 952.898.4006 or scanned to firstname.lastname@example.org.
- Authorization to Release Health Information Form.pdf
- Election of Hospice Benefit Form.pdf
- HIPAA Health Information Privacy Accountability Act Form.pdf
- Notice of Privacy Practices Form.pdf
- Patient Consent for Care Form.pdf
- Patient Rights and Responsibilities Form.pdf
- Understanding_Advanced_Directives Form.pdf
- Fax Referral Form
- Physician Evaluation & Treatment Order
- Local Coverage Determination-Terminal Status 2019
All people deserve love, compassion, and dignity at end-of-life. At Minnesota Hospice, we strive to empower people to live life as fully as possible on their terms. Our team is filled with experienced professionals dedicated to walking with you during this part of life’s sacred journey. We provide the highest level of hospice care possible to help people find meaning, purpose, love, and beauty in living before departing life peacefully.