This form is intended for use by Registered Hospice Agencies

Click 'Continue' to proceed to the Midwest Medical Examiner Hospice Pre-Registration
page. Once the completed form has been submitted, the registration will be in
effect for 180 days. At that time a new form must be submitted by the
registering agency.

If the patient has an Authorized Health Care Agent please fax a copy of the
Authorization Form to the Midwest Medical Examiner's Office at 763-324-1042.

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