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Alabama Medicaid Form 168: Hospice Certification

Alabama Medicaid requires a physician's certification of terminal illness for each hospice benefit period: the first two 90-day periods, then 60-day periods. On Form 168 the physician confirms the admitting diagnosis codes and signs and dates the row for each benefit period, attesting that the patient is terminally ill based on clinical judgment about the normal course of the illness.

Who completes it

The recipient's attending physician certifies the terminal illness; if the recipient has no primary attending physician, the hospice medical director may certify. The hospice enters patient, provider and benefit period details, and a nurse who takes a verbal order documents it.

Submitting and payment

How to submit it
The signed form goes back to the hospice, which submits it to Alabama Medicaid with the Form 167 hospice election; Form 165-A is the hospice cover sheet. For each later benefit period, the hospice must obtain written certification within two calendar days of its start.

Good to know

  • A verbal order is accepted for the initial certification only. The nurse receiving it signs, dates and prints the physician's name, and the physician must sign within 30 days.
  • Without a verbal order, the physician must sign within two days after hospice care begins, and the benefit period start should match the first billable service date.
  • The form warns that certifying chronic debilitating diagnoses as terminal without supporting documentation leads to referral to Alabama Medicaid's Program Integrity Unit.
  • The current Form 168 is revised 02-2026 and posted as an accessible PDF, with separate completion instructions on the long-term care forms page.

Get the official form

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

Hospice Certification

Official pagePDF

Fill it with Vero

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.

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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 Alabama Medicaid hospice Form 168?

The recipient's attending physician signs the certification of terminal illness. If the recipient does not have a primary attending physician, the hospice medical director may certify instead. The physician signs and dates the row for each benefit period and prints or types their name on the form.

How soon must the physician sign Form 168?

If a verbal order was taken for the initial certification, the physician must sign within 30 days of it. With no verbal order, the physician must sign within two days after hospice care starts. Each later benefit period needs written certification within two calendar days of the period's start.

Is a new Form 168 needed for each benefit period?

The form has rows for two 90-day and three 60-day certifications, and the instructions say to complete another Form 168 for subsequent 60-day periods, with the patient information at the top. The beneficiary's signature is not needed on those later forms.