Hospice Recertification Note (Benefit Period)

Hospice Recertification Note (Medicare 42 CFR 418.22)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN/Hospice ID: [Identifier]

Hospice Program: [Agency name/program]

Note Date: [Date of documentation]

Author: [Name, credentials, role]

Location/Place of Service: [Home / SNF / ALF / Hospital / Inpatient hospice / Other]

Primary Terminal Diagnosis: [Terminal diagnosis]

Contributing Diagnoses: [Relevant comorbidities contributing to prognosis]

Benefit Period

Benefit Period: [Benefit period number, e.g., "Benefit Period 4" / PENDING—benefit period dates not yet verified]

Benefit Period Dates: [Start date – End date / PENDING—benefit period dates not yet verified]

Recertification Signature Date: [Date]

Face-to-Face Required: [Yes / No]

(If any Benefit Period field is PENDING, treat this note as incomplete and resolve prior to final signature.)

Clinical Evidence of Decline

Data Sources Reviewed: [Sources reviewed, e.g., chart review, nursing notes, caregiver report, IDG input, outside records]

[Interval changes and current clinical status since last benefit period] (Provide a concise narrative summarizing decline trajectory. Clearly distinguish observed findings from reported findings by labeling the source. Include the following elements when documented and relevant: major interval events with dates; functional status with performance scale if available; nutritional status including weight trend with dates; symptom burden and escalating care needs; disease-specific progression indicators per LCD criteria. If a key metric is unavailable, briefly note why. Omit categories that do not apply rather than marking N/A. Do not infer measurements not obtained.)

Face-to-Face Encounter

(Include this section only if Face-to-Face Required is Yes for this recertification. Omit entirely if not required.)

F2F Date: [Date of encounter]

Practitioner: [Name, credentials]

Encounter Location: [Location]

Clinical Findings: [Exam findings supporting prognosis] (Summarize key observations: general appearance and frailty, functional status, respiratory effort, cognition and interaction, nutritional markers, and disease-specific findings as relevant. Keep brief and exam-focused.)

Attestation: [Statement confirming the face-to-face encounter occurred on the date above for hospice recertification] (If the examiner is not the certifying physician, include statement that findings were communicated to the certifying physician prior to recertification.)

Recertification Narrative

(This section must be free-text and patient-specific—not boilerplate. It must appear immediately before signatures.)

[Explicit recertification statement including benefit period number and dates, e.g., "I am recertifying that this patient remains terminally ill with a prognosis of six months or less if the illness runs its normal course for Benefit Period X (start date to end date)."]

[Synthesis of key decline since last benefit period] (Summarize 3–6 high-yield facts: functional decline, nutritional decline, complications, symptom escalation, disease progression. Be patient-specific.)

[Current severity snapshot restating functional status, nutritional status, and symptom burden]

(If face-to-face encounter was required, include 1–2 sentences explicitly linking F2F clinical findings to prognosis support.)

(If any findings suggest stabilization or improvement, briefly explain why overall prognosis remains six months or less.)

This narrative was personally composed by me based on my review of the medical record and clinical judgment.

Signatures

Certifying Physician: [Name, credentials]

Signature Date: [Date]

(Include below only if a separate practitioner performed the face-to-face encounter and this note serves as that documentation.)

Face-to-Face Practitioner: [Name, credentials]

Signature Date: [Date]