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Indiana Medicaid Hospice Physician Certification

Indiana Medicaid uses State Form 48736 (OMPP 0006) to document the medical basis for a member's hospice eligibility. It certifies that the member is terminally ill, with a life expectancy of six months or less if the illness runs its expected course. The hospice files it with the member's election and plan of care forms for fee-for-service members.

Who completes it

For the first benefit period, the attending physician and the hospice medical director both certify. For later benefit periods, the hospice medical director alone can complete and sign it.

Submitting and payment

How to submit it
For fee-for-service members, the hospice uploads it to the Atrezzo Provider Portal or faxes or mails it to the IHCP prior authorization and utilization management contractor; managed care members follow their plan's rules.
Who pays
The form sets no fee for the physician; it supports Medicaid coverage of the hospice benefit period.

Good to know

  • The certification is not required for members who are dually eligible for Medicare and Medicaid.
  • The member or representative elects hospice on a separate form, State Form 48737, which also has a Spanish version, State Form 55896.
  • The Medicaid Hospice Plan of Care, State Form 48731, needs the medical director's signature plus two interdisciplinary team signatures within 10 business days of the start of the benefit period.
  • Members 20 and younger can receive curative care alongside hospice; that plan of care uses State Form 54896.

Get the official form

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

Medicaid Hospice Physician 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 the Indiana Medicaid hospice physician certification?

In the first benefit period, both the attending physician and the hospice medical director certify the terminal illness. For subsequent benefit periods, Indiana allows the hospice medical director alone to complete and sign the form, without the attending physician.

Is the Indiana hospice certification needed for dual-eligible members?

No. Indiana Medicaid states that the Medicaid Hospice Physician Certification is not required for members who are dually eligible for Medicare and Medicaid. Nursing facility residents with dual eligibility have their own Hospice Authorization Notice, State Form 51098.