Hospice Certification of Terminal Illness Form

Hospice Certification of Terminal Illness Form
- Patient Name
  First NameLast Name
- Patient Date of Birth
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Patient ID Number
  Patient #
- Benefit Period
- I, Attending Physician undersigned, have reviewed this patient’s medical record according to examination of the patient,
  I certify this patient’s prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course. This certification of terminal illness is based on my clinical judgment regarding the normal course of the individual’s illness.
- By reviewing the patient’s clinical circumstances and medical information, the Hospice will provide clinical justification for admission to the patient. Physician's narrative:
- Physician Name
  First NameLast Name
- Date Signed
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Physician's Signature
  Clear
- Should be Empty: