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Hospice Certification of Terminal Illness Form Template

Streamline Your Process with Our Hospice Certification Template

Navigating hospice care can be stressful, especially when you need to document a terminal illness accurately. This template serves healthcare professionals who require a straightforward way to create a certification of terminal illness, ensuring that patients receive the necessary care promptly. Save time with easily customizable fields, facilitate quicker insurance approval, and maintain compliance with legal requirements, all while ensuring clarity and compassion in communication. Explore the live template to start simplifying your documentation process today.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Self-described gender (if applicable)
Medicare Beneficiary Identifier (MBI) or insurance ID
Primary phone number
Email address
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Hospice organization name
Hospice NPI
Hospice contact phone
Hospice contact email
Attending physician full name
Attending physician NPI
Attending physician phone
Attending physician email
Certifying clinician full name
Certifying clinician NPI
Specialty/credentials
Certifying clinician phone
Certifying clinician email
Benefit period status
Initial certification (Benefit period 1)
Initial certification (Benefit period 2)
Recertification (Benefit period 3 or later)
Unknown
Hospice election date
Certification start date
Certification end date
If Other location, please specify
Primary location of care
Patient home
Assisted living/residential care
Skilled nursing facility/long-term care
Inpatient hospice unit
Hospital
Other
Please Specify:
Primary terminal diagnosis (description)
Primary diagnosis ICD-10 code
Secondary diagnoses and significant comorbidities
Clinical summary supporting a prognosis of 6 months or less if the disease runs its normal course
Approximate functional status (PPS or Karnofsky equivalent)
10-20 percent
30-40 percent
50-60 percent
70 percent or higher
Not assessed or unknown
Other clinical factors (if selected above)
Pertinent exam findings, labs, or imaging
Recent clinical indicators (select all that apply)
Face-to-face encounter date
Encounter clinician full name
Encounter clinician role/title
Face-to-face encounter completed (if recertification)
Yes
No
Not applicable
Advance directives on file
Yes
No
Unknown
Not applicable
Patient or representative informed of hospice philosophy and services
Yes
No
Unknown
Certifying clinician signature
Signature date
Printed name of certifying clinician
I certify that the patient is terminally ill with a prognosis of 6 months or less if the disease runs its normal course
True
False
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Paper art illustration depicting a hospice certification form template for terminal illness documentation.

When to use this form

Use this form when an attending physician or hospice medical director must certify a prognosis of 6 months or less. It is useful at admission after an acute decline, when discharging from hospital to hospice, and at recertification. In these moments, you document the principal diagnosis, related conditions, and a brief narrative that supports eligibility. If you are coordinating new orders for symptom control, pair it with the Home health physician order form to align medications and services. To show ongoing decline between visits, pull details from a Caregiver daily log form. Done well, this documentation guides the plan of care, satisfies Medicare requirements, and helps prevent claim denials.

Must Ask Hospice Certification of Terminal Illness Questions

  1. What is the principal terminal diagnosis and which related conditions materially contribute to the prognosis?

    This establishes the medical basis for a life expectancy of 6 months or less and clarifies what is related to the terminal condition. Clear linkage strengthens your clinical narrative and supports coverage decisions.

  2. What is the patient's current functional status (PPS/KPS) and recent changes in ADLs, weight, and mobility?

    Objective decline demonstrates disease trajectory and substantiates eligibility. If ADL support is needed, verify competencies with the Home health aide skills checklist form.

  3. What recent clinical findings (vitals, labs, wounds, infections, imaging) support a limited prognosis?

    Concrete evidence anchors your narrative and shows why disease-directed treatment is no longer appropriate. Include dates and trends to show progression, not isolated events.

  4. What are the patient's goals of care, code status, and has the attending physician agreed with the prognosis?

    Aligning goals with the plan of care supports ethical, patient-centered decisions and reduces conflicts. Documenting attending concurrence meets regulatory expectations for certification and coordination.

  5. If this is a recertification, what has changed since the last benefit period and why does the 6-month-or-less prognosis remain reasonable?

    Addressing interval change is required to justify continued eligibility. A clear comparison to the prior certification speeds decisions and helps prevent denials.

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