TERMINAL ILLNESS LETTER

[Practice name]
[Address]
[Phone and email]

Date of this letter: [The date you sign it]
To: [Benefits program, insurer, or plan]
Reference: [Claim, policy, or application number, as the patient gave it]

Patient: [Full name]
Date of birth: [Date]

I am [patient name]'s [role, e.g. treating oncologist, family physician, or palliative care physician] and have cared for them since [date]. I last assessed them on [date], [in person, by video, or by phone].

CONDITION
Diagnosis: [The condition, with its stage or severity]
Diagnosed on: [Date, and how it was confirmed, e.g. biopsy, imaging, or lung function tests]

CURRENT STATE
[How the illness has progressed, the findings that show it, and what the patient can still do day to day]

TREATMENT AND GOALS
Can it be cured: [No, or the program's own words, e.g. cannot be cured or adequately treated]
Treatment so far: [What was tried, and anything stopped or declined]
Aim of care now: [e.g. comfort and symptom control, or treatment to slow the illness]

PROGNOSIS
The program asks: [Its question and time frame, copied from its form or policy, or none set]
My opinion: [Your answer in the program's terms, e.g. In my clinical judgment, death can reasonably be expected within 12 months]
Based on: [The course and findings that support this estimate]
This is an estimate from my clinical judgment, not a prediction of a date.

I discussed this letter with [patient name, or their substitute decision-maker], who knows what it says and agreed that I send it to [recipient].

Whether the claim is approved is for [recipient] to decide.

[Your name, credentials]
[License or registration number]
[Signature]
Practice phone, to verify this letter: [Phone]