Hospice election package self-check (2026 addendum rule)

Does the form name the hospice that gives the care?

If the patient chooses an attending (physician, nurse practitioner, or physician assistant), does the form have space for their full name and office address or NPI?

Does the patient acknowledge that the attending (if any) is their own choice?

Does it say hospice care is palliative, not curative?

Does it say the patient received information on what the hospice covers, and list the Medicare services the patient waives by electing hospice?

Does it say that care for unrelated conditions is "exceptional and unusual", and that the hospice gives virtually all needed care?

Does it have an effective date field?

Does it say the effective date cannot be earlier than the date signed?

Does it give information on the patient's cost-sharing?

Does it tell the patient about the right to immediate advocacy through the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization)?

Does it give the BFCC-QIO's name and phone number for your area?

Does it say the hospice will give every patient the addendum within 5 calendar days, not only "if you ask"?

Does it have signature and date-signed lines for the patient or representative?

Is the title exactly "Patient Notification of Hospice Non-Covered Items, Services, and Drugs"?

Does it name the hospice?

Does it have fields for the patient's name and hospice medical record identifier?

Does it identify the terminal illness and related conditions?

Does it list current conditions and the items, services and drugs the hospice will not cover because they are unrelated?

Is there space for a clinical explanation, in words the patient can understand, of why those items are unrelated and not needed for pain or symptom management?

Does it say that relatedness is decided for each patient, and that the patient should share the explanation with their other providers?

Does it give references to the clinical, policy or coverage guidelines used?

Does it state the purpose of the addendum?

Does it tell the patient about their right to immediate advocacy through the BFCC-QIO if they disagree?

Does it have a place for the patient's or representative's printed name, signature, and date signed?

Does it say that signing shows only that the patient received the form, not that they agree?

Does it have space to record, on the addendum, the reason if the patient refuses to sign?

Does it have a "date furnished" field (the date the patient received it, not the signature date)?

Does your admission process give the addendum to every new patient within 5 calendar days of the election effective date?

When an unrelated item, service or drug changes in the plan of care, does someone update the addendum within 3 calendar days?

Is the addendum filed with the election statement, and available to the patient's other providers and Medicare contractors on request?

Is the Notice of Election filed with your Medicare contractor within 5 calendar days of the effective date?

If a patient dies, revokes, or is discharged before the addendum is given or signed, does your process record the reason?

Does it identify the new attending (physician, nurse practitioner, or physician assistant), with full name and office address or NPI?

Does it have the effective date of the change, not earlier than the date signed?

Does the patient acknowledge that the change is their own choice?

Does it have a signature and date line?