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Run: Hospice Certification of Terminal Illness

Hospice Certification of Terminal Illness template for documenting the physician’s six-month prognosis, clinical narrative, and attestation needed for hospic...

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Patient and Certification Context

Patient Identifier (required)

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 (required)

Certification Effective Date (required)

Date the certification period begins.

Physician Information

Physician Name (required)

Physician NPI (required)

Enter the 10-digit National Provider Identifier.

Physician Role (required)

Attestation Date (required)

Date the physician signs the certification.

Terminal Illness Determination

Primary Terminal Diagnosis (required)

State the terminal diagnosis supporting hospice eligibility.

Related Comorbidities

Select comorbid conditions that materially affect prognosis.

Functional Status (required)

Choose the best overall functional level at the time of certification.

Clinical Findings Summary (required)

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 (required)

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 (required)

Attestation and Submission

Physician Attestation (required)

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.

Yes No N/A

Physician Signature (required)

Submission Notes

Optional notes for the reviewer or audit trail.

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