Hospice Pre-Registration

Legal Next of Kin / Authorized Health Care Agent

(Refer to MN Statute 149A.80 subdivision 2, if unsure who is next of kin)

Last name

First name

Middle name

Address (Street)

City

State

ZIP Code

Phone number

Relationship

Phone number - Bound/Hidden

If NOK is a Health Care Agent, the Health Care Directive must be attached here:

Next of Kin is unable to make funeral arrangements due to dementia or age

Power of Attorney / Decision-Maker for the next of kin

Last name

First name

Middle name

Address (Street)

City

State

ZIP Code

Phone number

Relationship

Phone number - Bound/Hidden

Does this patient have a medical history of TBI, paralysis, overdose, etc?

Yes

Describe and include dates

Attach Medical Records

In the past six months, has there been trauma or fracture(s)?

Yes

Describe and include dates

Attach Medical Records

I have verified with the certifying physician that the death record will be completed as follows:

Expected cause of death:

Any other diagnoses that may contribute to death?

Certifying physician (enter full name)

Physician's phone number

Date last seen

Phone number - Bound/Hidden

Registering hospice agency

License number

[Must be Licensed Agency]

Registered by (Last name, First name)

Phone number

Fax number

Phone number - Bound/Hidden

Email - A copy of the completed registration will be emailed to this address

Please confirm your email address

*This form will be retained in the coroner’s / medical examiner’s office and the registration will be in effect for 365 days from the date last seen by the physician. At that time, a new form must be submitted by the registering agency.

I have reviewed all of the information and I believe it to be correct.