Form DOM-1166 A Hospice Discharge / Hospice Revocation Form - Mississippi

What Is Form DOM-1166 A?

This is a legal form that was released by the Mississippi Division of Medicaid - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form DOM-1166?
A: Form DOM-1166 is the Hospice Discharge/Hospice Revocation Form in Mississippi.

Q: What is the purpose of Form DOM-1166?
A: The purpose of Form DOM-1166 is to document the discharge or revocation of hospice services in Mississippi.

Q: How can I obtain Form DOM-1166?
A: You can obtain Form DOM-1166 from the Mississippi State Department of Health or the hospice provider.

Q: When should Form DOM-1166 be completed?
A: Form DOM-1166 should be completed when a patient is being discharged from hospice care or when the patient decides to revoke hospice services.

Q: What information is required on Form DOM-1166?
A: Form DOM-1166 requires information such as the patient's name, date of discharge/revocation, reason for discharge/revocation, and signatures of the patient and hospice provider.

Q: Are there any fees associated with Form DOM-1166?
A: No, there are no fees associated with Form DOM-1166.

Q: What should I do with the completed Form DOM-1166?
A: The completed Form DOM-1166 should be submitted to the appropriate authority, such as the Mississippi State Department of Health or the hospice provider.