🏥 Hospice Waiver Application – Professional Notification & Documentation Form

RCFE & Assisted Living Compliance Template

Rosenthal Community Care Services

📋 Ensure Proper Hospice Communication & Regulatory Compliance

The Hospice Waiver Application Form by Rosenthal Community Care Services is a professionally designed, non-editable digital documentation tool created for RCFE (Residential Care Facilities for the Elderly), ARF (Adult Residential Facilities), Assisted Living Facilities, Board and Care Homes, Memory Care Facilities, and Hospice Care Providers.

This form is used to formally document and communicate a resident’s change in condition or behavior, along with required notifications to both family/conservators and physicians, ensuring timely medical coordination and compliance with facility and hospice care requirements.

📄 Purpose of This Form

The Hospice Waiver Application is used to document a resident’s change in health status and facilitate proper communication between the facility, family or conservator, and the attending physician.

It ensures that all relevant parties are informed of the resident’s condition, physician recommendations, and any required medical or care plan adjustments.

This form supports structured documentation for care escalation, hospice coordination, and medical decision-making processes.

📑 Section 1: Notification to Family / Conservator

🏡 Facility Information

✔ Name of Facility
✔ Facility License Number
✔ Facility Address
✔ Administrator Name
✔ Phone Number

👨👩👧 Family / Conservator Contact

✔ Recipient Name (TO)
✔ Phone Number
✔ Address
✔ Fax Number

👤 Resident Information

✔ Resident Name

📝 Change in Condition Report

✔ Description of change in resident condition or behavior
✔ Physician recommendations section

📞 Communication Record

✔ Notification by phone completed
✔ Date of notification

📑 Section 2: Notification to Physician

🏥 Facility Information

✔ Name of Facility
✔ Facility License Number
✔ Facility Address
✔ Administrator Name
✔ Phone Number

👨⚕️ Physician Contact Information

✔ Physician Name (TO)
✔ Phone Number
✔ Address
✔ Fax Number

👤 Resident Information

✔ Resident Name

📝 Medical Update Section

✔ Change in condition details requiring physician review
✔ Instructions for care plan actions
✔ Current medications list

⭐ Key Features

✅ Professional non-editable PDF form
✅ Dual notification system (Family + Physician)
✅ Designed for RCFE, ARF, Assisted Living & Hospice coordination
✅ Supports change-in-condition reporting and care escalation
✅ Helps maintain compliance and accurate resident records
✅ Structured for medical and administrative communication
✅ Instant digital download
✅ Print-ready format
⚠️ No physical product shipped

🏡 Ideal For

✔ Residential Care Facilities for the Elderly (RCFE)
✔ Adult Residential Facilities (ARF)
✔ Assisted Living Facilities
✔ Board and Care Homes
✔ Memory Care Facilities
✔ Hospice Care Providers
✔ Facility Administrators
✔ Nurses & Care Coordinators
✔ Compliance Officers