New Jersey Medicaid and NJ FamilyCare use this short statement for the attending physician to certify, or later recertify, that a beneficiary is terminally ill and qualifies for hospice. The physician states that life expectancy is six months or less if the illness follows its usual course and that hospice services are reasonable and necessary. It becomes part of the hospice's election paperwork.
The attending physician writes in their name and the beneficiary's name and Medicaid/NJ FamilyCare ID, then signs, prints their name and dates the form.
Download the current version from the source each time; forms change without notice.
Physician's Certification/Recertification for Hospice Benefits
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The attending physician certifies that the beneficiary, who is under their care, is terminally ill with a life expectancy of six months or less if the illness follows its usual course, and that hospice services are reasonable and necessary to treat the terminal illness or related conditions.
Yes. The title reads Physician's Certification/Recertification for Hospice Benefits, and the statement lets the attending physician certify or recertify. The same one-page form is signed, printed and dated each time, then returned to the hospice for its records.