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Get Physician Certification of Terminal Illness

Osis of _______________ this patient, ____________________, is terminally ill with a life expectancy of six (6) months or less if the terminal illness runs its normal course. Verbal Certification from: _____________________by___________________ / ______ (Attending Physician) (Staff Member Signature) (Date) Attending Physician’s Signature____________ Date ______ Verbal Certification from: ____________________by___________________ / _______ (Medical Director) Staff Member Signature) (Date) Medic.

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