Terminal illness 2026

1. Click ‘Get Form’ to open the terminal illness certification in our editor.
2. Begin by entering the recipient number in field 1. This unique identifier is essential for processing.
3. In field 2, input the recipient's name, clearly identifying the patient for whom this certification applies.
4. For field 3, provide a written diagnosis of the patient's condition. Be specific to ensure clarity.
5. Enter the ICD/CM diagnosis code in field 4. This code is crucial for medical records and insurance purposes.
6. Indicate whether this is an initial certification or recertification in field 5 by checking the appropriate box.
7. The attending physician must sign in field 6 and date it in field 7 to validate the certification.
8. Field 8 requires the signature of the medical director, followed by their date in field 9.
9. Finally, have the interdisciplinary team physician sign and date in fields 10 and 11 respectively to complete the form.

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