Get Form Psc-801 Orig. 110205 Physician Certification ... - Icarol

The Form PSC-801 Orig. 110205 PHYSICIAN CERTIFICATION is a crucial document for certifying serious illness or the need for life support equipment. This guide provides clear, step-by-step instructions to ensure that users can accurately complete the form online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the name of the person who is the subject of the certification in the designated space provided.
3. Complete the address section by filling in the street address, city, state, and zip code of the individual.
4. Input a telephone number to ensure contactability if further information is required.
5. Indicate the relationship to the individual named in the certification.
6. Provide the account number associated with the individual's service.
7. Next, the licensed physician must complete their section, certifying the condition of the individual.
8. Select the applicable box indicating whether termination of service will aggravate an existing serious illness or prevent the use of necessary life support equipment.
9. The physician should print their name, license number, title, and address in the specified fields.
10. Input the office number and fax number, along with an optional e-mail address for communication.
11. Finally, the physician must sign the certification and indicate the date of signing.
12. Review the completed form for accuracy, then save your changes. You can also download, print, or share the completed form as needed.

Complete the necessary documents online today for efficient processing.