Get Terminal Illness

This guide provides clear, step-by-step instructions for completing the Terminal Illness certification online. This document is essential for certifying a patient's prognosis and ensuring they receive the appropriate support and services.

Follow the steps to complete the Terminal Illness certification online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the first field labeled 'Recipient number', enter the unique identification number assigned to the patient.
3. In the next field, 'Recipient name (patient)', input the full name of the patient as it appears on their official documents.
4. For the section titled 'Written diagnosis', provide a clear and precise description of the medical condition affecting the patient.
5. Enter the appropriate 'ICD/CM diagnosis code' that corresponds to the patient's diagnosis. This code helps standardize the diagnosis.
6. Indicate whether this is an 'Initial Certification' or a 'Recertification' by checking the applicable box.
7. The attending physician needs to sign in the designated 'Signature of patient’s attending physician' field, confirming the diagnosis.
8. Fill in the 'Date' field next to the attending physician's signature with the date on which the certification is being signed.
9. The medical director must also provide their signature in the 'Signature of medical director' section.
10. Complete the 'Date' field next to the medical director's signature with the appropriate date.
11. Finally, the interdisciplinary team physician should sign in the 'Signature of interdisciplinary team physician' field and enter the date.
12. Once all fields are completed, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Start filling out your Terminal Illness certification online today to ensure timely support.