Hospice Certification of Terminal Illness

Documents physician certification of terminal illness and the clinical narrative supporting a six-month prognosis for hospice eligibility.

Certification Details

• Certification Type
• Certification Date
  Date the certifying physician completed and signed the certification.
• Certification Period Start Date
• Certification Period End Date

Patient Eligibility Summary

• Patient Identifier
  Use the hospice or medical record identifier rather than SSN or other unnecessary PII.
• Primary Hospice Diagnosis
• Related Comorbidities
  Select conditions that materially support the prognosis.
• Functional Status Summary
  Briefly describe current functional decline, ADL dependence, mobility limitations, and other observable indicators relevant to prognosis.

Clinical Narrative Supporting Six-Month Prognosis

• Clinical Narrative
  Summarize the clinical basis for terminal prognosis, including disease progression, recent hospitalizations, weight loss, symptom burden, functional decline, and other relevant findings.
• Primary Basis for Prognosis
• Recent Clinical Findings
  Include only findings relevant to prognosis, such as vital trends, exam changes, labs, imaging, or treatment response.

Attestation and Signature

• Certifying Physician Name
• Physician NPI
  Optional if your organization already links the certifying clinician in the audit trail.
• Attestation Statement
• Physician Signature
• Signature Date

Submission Notice

• What happens after I submit?