This form is intended for use by Registered Hospice Agencies

The user is accessing a restricted information system. System usage may be monitored, recorded and subject to audit. Unauthorized use of the system is prohibited and may be subject to criminal and/or civil penalties. Use of the system indicates consent to monitoring and recording.

Click 'Continue' to proceed to the Hennepin County Medical Examiner Hospice Pre-Registration page. This form will be retained by the 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.