Attach Document (required)

In order to determine if a patient is eligible for Hospice benefit we are required to have physician's authorization with a brief narrative supporting terminal illness.

Patient Name:

Statement for First 90-­‐day period

Verbal Authorization Date:
Effective Date of Certification:

Terminal Diagnosis:

It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice. I have been encouraged to participate in the IDG Meetings and Plan of Care if I choose to follow the Patient.

Name*:
Referring MDPCPOther MD

Signature*:
Referring MDPCPOther MD

Patient Follow-­‐Up (Please check one)

I DO wish to be contacted directly should the need arise for a change in the current plan of care. The Hospice Physician can be designated in my absence. I wish to sign the Death Certificate. The Hospice Physician can follow for pain and symptom management.

DO NOT want to follow the patient and/or sign the death certificate.