PivotChart

Step 1 — Patient Information

Enter the patient's demographic and contact information.

Patient Demographics

First Name *

Last Name *

Middle Initial

Date of Birth *

Gender *

SSN (last 4)

Medicare MBI *

Medicaid ID (if applicable)

Address & Contact

Street Address *

City *

State *

ZIP *

Phone *

Language

Emergency Contact / Healthcare Proxy

Proxy Name *

Relationship *

Proxy Phone *

Proxy Email

Step 1 of 6

Step 2 — Medicare / Medicaid Eligibility

Verify insurance eligibility before admission to avoid claim denials.

ℹ️ Run eligibility verification now to confirm Medicare Part A is active and the hospice benefit is available. A Medicare denial after admission creates financial liability for your agency.

Medicare Eligibility

Medicare Part A Status *

✅ Active — verified

❌ Not enrolled

⚠️ Needs verification

Part A Effective Date

Benefit Period Available *

Prior Hospice in This Benefit Period?

No — first election

Yes — prior hospice (obtain NOF)

Verified via

HETS / Availity

Clearinghouse 270/271

Medicare.gov portal

Phone 1-800-633-4227

Medicaid (if applicable)

Medicaid Active?

Yes — active

N/A — Medicare only

Medicaid Program / State

MCO Name (if managed care)

Overall Eligibility Decision

Eligibility Status *

✅ Eligible — proceed with admission

⚠️ Eligible with conditions

❌ Not eligible — do not admit

Eligibility Notes

Step 2 of 6

Step 3 — Terminal Diagnosis & Prognosis

Document the primary terminal diagnosis and clinical basis for hospice eligibility.

⚠️ The certifying physician must attest that the patient has a life expectancy of 6 months or less if the disease follows its expected course. Document the clinical basis carefully — this is the #1 audit target.

Primary Terminal Diagnosis

Primary Diagnosis *

ICD-10-CM Code *

Related / Comorbid Diagnoses

Prognosis — Life Expectancy *

6 months or less if disease follows expected course

3 months or less

Days to weeks

Clinical Eligibility Indicators

Disease-Specific Decline Indicators *

Current Functional Status

Weight Loss (last 30 days)

Nutritional Status

Attending Physician Name *

Physician NPI *

Certification Date *

Step 3 of 6

Step 4 — Hospice Election & Consents

Patient or representative must sign the election statement to start the hospice benefit.

⚡ NOE Filing Deadline: Once the election date is set, you have exactly 5 calendar days to file the Notice of Election with Medicare. A reminder will be created automatically.

Hospice Election

Hospice Election Date *

NOE Filing Deadline (auto-calculated)

Benefit Period *

Period 1 — Days 1–90

Period 2 — Days 91–180

Period 3+ — 60-day extension

Patient / Representative Consent

"By signing below, I elect to receive hospice care from this hospice agency. I understand that I am choosing comfort-focused care and am waiving Medicare coverage for curative treatment of my terminal illness. I understand I may revoke this election at any time."

Patient / representative verbally affirmed understanding of hospice election

Election statement signed and dated

Patient rights provided in writing in patient's language

DNR / POLST order discussed and documented

Advance directive reviewed / updated

Signed by *

Patient (competent)

Healthcare Proxy / Representative

Legal Guardian

Signature Name (type full name) *

Date Signed *

Hospice Staff Witness *

Step 4 of 6

Step 5 — Assign Care Team & Schedule

Assign all IDG members and schedule the first visits.

Interdisciplinary Group (IDG) Assignment

Primary RN *

Hospice Medical Director *

Social Worker

Chaplain / Spiritual Care

Hospice Aide

Volunteer

First Visits to Schedule

Initial RN Assessment (48hr deadline) *

Initial SW Visit

First Chaplain Visit

Goals of Care Discussion (MD)

HIS Admission Target Submission Date (7-day deadline) *

Initial Visit Frequency Plan

RN Visit Frequency *

Aide Frequency

SW Frequency

Step 5 of 6

Step 6 — Review & Complete Admission

Review the admission summary before finalizing.

✅ All required steps completed. Review the checklist below, then click Complete Admission to create the patient record and trigger all follow-up tasks.

Admission Checklist

Patient demographics — Name, DOB, MBI, address

Medicare eligibility — Part A active, Period 1 available

Terminal diagnosis — ICD-10 coded, physician certified

Hospice election statement — signed and dated

Patient rights — provided in writing

Care team assigned — RN, MD, SW, Chaplain

Initial visits scheduled — 48-hr RN, Goals of Care

DNR / advance directive — reviewed and on file

Auto-Generated Tasks After Admission

⚡NOE filing reminder — 5-day deadline (HIGH priority)

📊HIS Admission submission — 7-day CMS deadline

📋Comprehensive assessment — 5-day deadline

📋Initial care plan — 5-day deadline after comprehensive assessment

👥First IDG review — scheduled within 15 days

Step 6 of 6

🎉

Patient Successfully Admitted!

The patient record has been created in Medplum. All follow-up tasks have been generated and assigned. The NOE filing deadline has been flagged as urgent.

⚡ Immediate Action Required

📬

File Notice of Election (NOE) — Medicare MAC deadline is 5 days from election date

Today

🩺

Complete 48-hour RN Initial Assessment — CMS required within 48 hours

48 hrs

📊

Submit HIS Admission to CMS iQIES — Required within 7 days

7 days

📋

Complete comprehensive assessment and care plan

5 days

👥

Schedule first IDG meeting

15 days

🚪 New Hospice Admission