Midwest Medical Examiner's Office
This form is intended for use by Registered Hospice Agencies
Click 'Continue' to proceed to the Midwest Medical 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.