HOPE Assessment Application

Section A - Administrative Information

Provider identification, patient demographics, and payer information

Provider Information

A0050 - Type of Record*

A0100A - National Provider Identifier*

Format: 10 digits

A0100B - CMS Certification Number*

Format: SSPPPP (e.g., 051234)

A0100C - Branch Identifier

Format: CCCCCCBBBB (6-digit CCN + 4-digit branch)

A0200 - State

Two-character state code

Assessment Information

A0220 - Admission/Event Date*

Format: YYYY-MM-DD

A0220C - Assessment Reference Date

Format: YYYY-MM-DD (Optional)

A0250 - Reason for Record*

Patient Identification

A0320B - Patient Identifier

A0500 - Patient Legal Name

First Name*

Middle Initial*

Last Name*

Suffix*

A0600A - Social Security Number*

Format: XXX-XX-XXXX

A0600B - Medicare Number*

11-character Medicare MBI

A0700 - Medicaid Number*

Enter ID, 'N', or '+'

Patient Demographics

A0810 - Sex*

A0900 - Birth Date*

Format: YYYY-MM-DD

Section J - Health Conditions

Patient health status assessment and symptom impact screening

J0050 - Death is Imminent

Does patient appear to have a life expectancy of 3 days or less?*

J2050 - Symptom Impact Screening

Screening to assess how patient has been affected by symptoms over the past 2 days

J2050A - Was Symptom Impact Screening completed?*

Section M - Skin Conditions

Assessment of patient skin conditions and treatments in place

M1190 - Does the patient have one or more skin conditions?*

Section N - Medications

Opioid medication management and bowel regimen tracking

N0500 - Scheduled Opioid

Track whether scheduled (around-the-clock) opioid medication was initiated or continued

N0500A - Was a scheduled opioid initiated or continued?*

N0510 - PRN (As-Needed) Opioid

Track whether PRN (pro re nata / as-needed) opioid medication was initiated or continued

N0510A - Was a PRN opioid initiated or continued?*

Section Z - Record Administration

Assessment completion date, signatures, and verification

Z0350 - Date Assessment Completed*

Format: YYYY-MM-DD

Z0400 - Signature(s) of Person(s) Completing the Record

Signatures of all clinicians who completed sections of this assessment (up to 12)

No signatures added yet. Click "Add Signature" to add a clinician signature.

⚠️ Verification Signature Required: A supervising clinician must verify the accuracy and completeness of this assessment before submission.

Z0500 - Signature of Person Verifying Record Completion

Final verification signature confirming assessment accuracy and completeness

Z0500A - Verification Signature (Name)*

Full name with credentials

Z0500B - Date of Verification*

Format: YYYY-MM-DD

Update Visit (HUV) Assessment

Update Visit Assessment Instructions

Section A - Administrative Information

Provider Information

Assessment Information

Patient Identification

A0500 - Patient Legal Name

Patient Demographics

Payer Information

Section J - Health Conditions

J0050 - Death is Imminent

J2050 - Symptom Impact Screening

Section M - Skin Conditions

Section N - Medications

N0500 - Scheduled Opioid

N0510 - PRN (As-Needed) Opioid

Section Z - Record Administration

Z0400 - Signature(s) of Person(s) Completing the Record

Z0500 - Signature of Person Verifying Record Completion