Hospice Form - NHPRI.org

Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member's ID#*
Member's DOB*
MM slash DD slash YYYY
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Name*
First Last
Error Message
Hospice Agency Information
Hospice Agency NPI*

10 digits
Hospice Agency Name*
Error Message
Agency Phone #*
Agency Fax #*
Contact Name*
Email address in order to receive confirmation of request receipt*

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Clinical Information
Ordering MD*
Ordering MD Phone #*
Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
HCPC/CPT Code (Click + or - at the right to add up to 5 Codes)*
Code Type Code

Example HCPC code: S1234 with modifier: S1234 U1 Example CPT code: 12345
Place of Service*
Place of Service *
- Hospital Inpatient
- SNF
- Philip Hulitar
Name of Facility*
List all Durable Medical Equipment
(provided under Hospice Benefit)

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Attach Clinical*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10.
Upload only PDF or Word Document
Per EOHHS, Neighborhood cannot pay for services provided by individuals legally responsible for the member
Signature of Treating Provider*
Signature Date:*
Request Method*
Request Method *
- Standard
- Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
  Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
Attach additional Clinical documents for Expedited request*
Accepted file types: pdf, doc, docx, Max. file size: 13 MB.
Upload only PDF or Word Documents
Signature of Physician or Licensed Provider (Required for Expedited request)
Signature Date:*
Comments
Authorization is not a guarantee of payment
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Diagnosis	ICD 10 Diagnosis Code

Code Type	Code

Member Information