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PHYSICIAN CERTIFICATION OF TERMINAL ILLNESS Patient Name: Chart #: 1. Patient Certification Please provide a diagnosis, narrative, and complete signature section. I certify that the patient named.

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1. Identification of the particular hospice and of the attending physician that will provide care to the individual. The individual or representative must acknowledge that the identified attending physician was his or her choice.

The POC must include all services necessary for the palliation and management of the terminal illness and related conditions of the individual. The hospice POC should link with the needs identified in the initial/comprehensive assessment.

I certify that ____________________________________________ is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course.

A brief narrative, written by the certifying physician, explaining the clinical findings that support the patient's life expectancy of six months or less. This narrative can be a part of the certification/recertification form or as an addendum to the form.

The narrative summary should include objective data or metrics, such as height, weight, body mass index, mid-arm circumference, Karnofsky Performance Score (KPS), Palliative Performance Score (PPS), Functional Assessment Staging Scale (FAST), New York Heart Association class (NYHA) and pertinent diagnostic test results ...

One component of the hospice certification of terminal illness (CTI) requirements is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician.

Under both the hospital insurance and supplementary medical insurance programs, when services are continued past an initial 60-day episode of care, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services in ance with requirements described in Pub.

The narrative shall include a statement, located above the physician signature and date, that attests to the fact that by signing the form, the physician confirms that he/she composed the narrative based on his/her review of the patient's medical record or his/her examination of the patient.

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Keywords relevant to INITIAL PHYSICIAN CERTIFICATION - Hospiceoflansing

  • limiting
  • Lansing
  • narrative
  • Prognosis
  • Guidelines
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232