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Run: Hospice Certification of Terminal Illness

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

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Certification Details

Certification Type (required)

Certification Date (required)

Date the certifying physician completed and signed the certification.

Certification Period Start Date (required)

Certification Period End Date (required)

Patient Eligibility Summary

Patient Identifier (required)

Use the hospice or medical record identifier rather than SSN or other unnecessary PII.

Primary Hospice Diagnosis (required)

Related Comorbidities

Select conditions that materially support the prognosis.

Functional Status Summary (required)

Briefly describe current functional decline, ADL dependence, mobility limitations, and other observable indicators relevant to prognosis.

Clinical Narrative Supporting Six-Month Prognosis

Clinical Narrative (required)

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 (required)

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 (required)

Physician NPI

Optional if your organization already links the certifying clinician in the audit trail.

Attestation Statement (required)

Yes No N/A

Physician Signature (required)

Signature Date (required)

Submission Notice

What happens after I submit?

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Email (required)

Your name (optional)

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