PATIENT'S NAME__________________________________HOSPICE OF WARREN COUNTY

ADDRESS ________________________________________2 CRESCENT PARK WEST
_________________________________________________WARREN, PA 16365
_________________________________________________PROVIDER NO. 39-1551

MEDICARE HOSPICE BENEFIT REVOCATION

As a Medicare Hospice beneficiary, I wish to revoke the election of Medicare coverage of hospice care for the remainder of benefit period #__________.

I understand that I am forfeiting the right to __________ days of hospice coverage in the current benefit period. Should I choose to re-elect the Medicare Hospice benefit at a later time, I retain the right to use __________ days in benefit period #__________, and, if applicable, unlimited 60 day benefit periods.

THE BENEFIT PERIODS ARE AS FOLLOWS:

FIRST BENEFIT PERIOD - 90 DAYS
SECOND BENEFIT PERIOD - 90 DAYS
UNLIMITED 60 DAYS

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I DIRECT THIS REVOCATION TO BE EFFECTIVE ON __________________________________

I UNDERSTAND THAT THE MEDICARE HEALTH CARE BENEFITS WHICH I WAIVED TO RECEIVE HOSPICE MEDICARE COVERAGE WILL BE RESUMED ON THE ABOVE DESIGNATED DATE.

SIGNATURE OF BENEFICIARY OR LEGAL REPRESENTATIVE DATE

RELATIONSHIP OF LEGAL REPRESENTATIVE TO BENEFICIARY

WITNESS SIGNATURE DATE

*** Hospice Revocation cannot be effective prior to the date this form is signed. A beneficiary may designate the effective date to be the same date as the signature date or a date in the future.

Revised 02/21/02