Hospice Certification of Terminal Illness

The attending physician uses this document to state that a patient meets the clinical criteria for palliative care coverage. It identifies the patient, marks which benefit period is being certified, and captures the narrative that justifies admission. A dated signature closes the record so it can be filed or sent to the payer.

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Section

Patient Name

Nombre

Apellido

Patient Date of Birth

Patient ID Number

Section

Benefit period being certified

First 90-day period Second 90-day period Subsequent 60-day period Recertification

Physician certification statement

After reviewing the patient's clinical situation and records, set out the medical justification for admission (physician narrative):

Physician Name

Nombre

Apellido

Date Signed

Physician's Signature

Sign here

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