Patient Notification of Hospice Non-Covered Items, Services, & Drugs
UPDATED 2021
The purpose of this addendum is to notify the requesting Medicare beneficiary (or representative), in writing, of those conditions, items, services, and drugs not covered by the hospice because the hospice has determined they are unrelated to the beneficiaries' terminal illness and related conditions.
Size: 8 ½ “ x 11”
Print: 2-sides different; Black Ink
Punching: 5-holes top and side
Paper: White
Packaging: 100 per pad