Hospice Certification of Terminal Illness

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

Patient and Certification Context

• Patient Identifier
  Use the medical record number or internal patient ID. Do not enter SSN.
• Patient Initials
  Optional secondary identifier if needed for chart matching.
• Certification Type
• Certification Effective Date
  Date the certification period begins.

Physician Information

• Physician Name
• Physician NPI
  Enter the 10-digit National Provider Identifier.
• Physician Role
• Attestation Date
  Date the physician signs the certification.

Terminal Illness Determination

• Primary Terminal Diagnosis
  State the terminal diagnosis supporting hospice eligibility.
• Related Comorbidities
  Select comorbid conditions that materially affect prognosis.
• Functional Status
  Choose the best overall functional level at the time of certification.
• Clinical Findings Summary
  Summarize the findings that support a prognosis of six months or less if the illness runs its normal course.

Clinical Narrative and Prognosis

• Clinical Narrative
  Include disease progression, objective findings, functional decline, symptom burden, and the rationale for the six-month prognosis.
• Indicators of Decline
  Select all that apply to support the prognosis.
• Prognosis Statement

Attestation and Submission

• Physician Attestation
  I certify that the patient is terminally ill and that the clinical narrative supports a prognosis of six months or less if the illness runs its normal course.
• Physician Signature
• Submission Notes
  Optional notes for the reviewer or audit trail.