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:

Certification #1: Statement for First 90-­‐day period

I certify that has a life expectancy of six months or less, if the terminal illness runs its normal course.

Verbal Authorization Date: Obtained by:

Effective Date of Certification:

Primary DX:

Secondary DX:

Comorbidities:

Medical history,record and patient statusTeam AssessmentFace to Face Encounter

ADL:

Functional Status:

LCD Determination Status:

RN Assessment Narrative:

Physician Narrative:

Medical Director Attestation/Certification

I attest/confirm that I composed this narrative based on my review of patient’s medical records,
team assessment and/or examination of the patient.

Medical DirectorPhysician DesigneeReferring MD (if attending)