Pennsylvania Medical Assistance uses this one-page certification so a recipient can elect the hospice benefit. The physician writes the diagnosis and its ICD-CM code and states that, in their professional opinion, life expectancy is six months or less. The form marks whether it is an initial certification or a recertification and has three dated physician signature lines.
The patient's attending physician and the hospice medical director sign, and a third line is for the interdisciplinary team physician. Each signature has its own date.
Download the current version from the source each time; forms change without notice.
Certification of Terminal Illness
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The form has three signature lines: the patient's attending physician, the hospice medical director and the interdisciplinary team physician, each with a date. Together they certify the written diagnosis and that the recipient's life expectancy is six months or less in their professional opinion.
Yes. The form has checkboxes for initial certification and recertification, so the same one-page certification is completed again when the hospice recertifies. The hospice keeps each signed form with the recipient's election documentation.