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Missouri 2575-031 Terminal Illness Certification

MO HealthNet's form 2575-031 certifies that a participant electing hospice is terminally ill, with a probable life expectancy of six months or less if the illness runs its expected course. It covers the initial 90-day period, a second 90-day recertification and continuing 60-day recertifications, each signed by a physician who confirms having reviewed a current plan of care.

Who completes it

For the initial 90-day certification, both the attending physician and the hospice medical director sign, each with the date of any verbal order. A physician signs each recertification. The hospice enters participant identifiers and its NPI, Medicare provider identifier and taxonomy code.

Submitting and payment

How to submit it
Return the signed form to the hospice, which keeps it with the 2575-029 Hospice Election Statement. The attending physician must sign within eight days of the date of the hospice election.

Good to know

  • Page 1 holds the initial certification and recertifications through the fifth period; page 2 continues through the thirteenth, and later periods are renumbered.
  • Every recertification statement says the physician has reviewed a current plan of care, so the plan should be current before each signature.
  • The participant block asks for the MO HealthNet ID, the Medicare health insurance claim (HIC) number and the Social Security number.
  • The form is dated March 2023. The hospice set also includes 2575-029, the election statement, and 2575-027, Notification of Termination of Hospice Benefits.

Get the official form

Download the current version from the source each time; forms change without notice.

Physician Certification of Terminal Illness

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who signs MO HealthNet form 2575-031?

The initial 90-day certification has signature lines for both the attending physician and the hospice medical director, each with a line for the date of a verbal order. Recertifications for the second and later benefit periods are signed by a physician, with from and through dates for each period.

How soon must the attending physician sign form 2575-031?

Within eight days of the date of the hospice election. The certification states that, to the best of the physician's medical knowledge, the participant is terminally ill with a probable life expectancy of six months or less if the illness runs its expected course.

How often is hospice recertified under MO HealthNet?

After the initial 90 days and a second 90-day period, MO HealthNet requires continuous recertification every 60 days. The form provides rows through the thirteenth period across two pages, and recertifications beyond the thirteenth are renumbered on another page.