Hospice Physician Certification of Terminal Illness (Initial)

Patient Name: [Patient full name]

Date of Birth: [DOB]

MRN: [Medical record number]

Hospice Provider: [Hospice organization name]

Document Date: [Date document completed]

Patient Location: [home / SNF / inpatient hospice unit / hospital / assisted living / LTACH / other]

Benefit Period Information

Benefit Period: Initial Certification

Benefit Period Start Date: [Start date]

Benefit Period End Date: [End date]

Hospice Election Effective Date: [Election date] (Include only if available; otherwise omit this line)

Certifying Physicians

Hospice Certifying Physician: [Name, credentials]

Role: [Medical Director / IDG Physician / Hospice Physician]

Patient-Designated Attending Physician: [Name, credentials, specialty/relationship] (If no attending physician designated, state: "No attending physician designated for hospice." If one physician serves both roles, document this explicitly.)

Terminal Diagnosis and Related Conditions

• Terminal (Principal) Hospice Diagnosis: [Diagnosis with ICD-10 code if available]
• Related Conditions Contributing to Terminal Prognosis: [List conditions that directly contribute to terminal trajectory]
• Significant Comorbidities Impacting Prognosis: [List comorbidities only if they materially affect prognosis]

Supporting Clinical Findings

(Provide structured evidence supporting terminal trajectory. Include dates and trends from baseline to current. Omit categories that do not apply. Do not infer or fabricate objective data not documented in the record.)

Disease Progression:

• [Objective indicators of progression with dates]
• [Treatment course: disease-directed therapies tried/failed, intolerance, patient declined further treatment, or goals shifted to comfort]

Functional Status:

• [Performance scale with trend if measured, e.g., "PPS: 40% (2026-01-12); was 60% (2025-12-01)"] (If not available, state "not available")
• [ADL dependence: specify activities requiring assistance]
• [Mobility status: ambulatory / limited ambulation / chairbound / bedbound]

Nutritional Status:

• [Weight trend with dates and percent loss if known] (If not available, state "not available")
• [Oral intake: adequate / poor / minimal; note dysphagia or aspiration risk if present]
• [Relevant labs with dates if already available, e.g., albumin] (Do not order new tests)

Complications and Sentinel Events:

• [Recurrent infections, pressure injuries with stage, aspiration events, falls, hospitalizations, or ED visits related to terminal condition—include dates]

Symptom Burden:

• [Key symptoms: pain, dyspnea, nausea, delirium, fatigue]
• [Escalation of management: increasing opioid requirements, oxygen needs, adjuvant therapies]

Hospice Physician Certification

Physician Narrative: [2–6 sentence patient-specific narrative synthesizing: terminal condition and trajectory; key decline indicators with dates; current functional state and dependence; nutritional status if relevant; complications or recent utilization. Conclude with explicit statement that life expectancy is six months or less if the disease runs its normal course.] (Must be individualized free-text, not boilerplate.)

Attestation: By my signature below, I confirm that I composed this narrative based on my review of the patient's medical record and/or my examination of the patient.

Printed Name: [Hospice certifying physician name]

Credentials: [Degree(s)/credentials]

Role: [Medical Director / IDG Physician / Hospice Physician]

Signature: _______________________________

Date of Signature: [Date]

Attending Physician Certification

(Include this section only if an attending physician is designated. If no attending is designated, omit entirely.)

Attending Physician Narrative: [2–6 sentence patient-specific narrative authored by the attending physician covering: terminal condition and trajectory; key decline indicators; functional state; nutritional status if relevant; complications. Conclude with explicit statement that life expectancy is six months or less if the disease runs its normal course.]

Attestation: By my signature below, I confirm that I composed this narrative based on my review of the patient's medical record and/or my examination of the patient.

Printed Name: [Attending physician name]

Credentials: [Degree(s)/credentials]

Specialty/Relationship: [Specialty or relationship to patient]

Signature: _______________________________

Date of Signature: [Date]