Home
Forms Library
Physician certification of terminal illness form

Certification terminal illness 2026

physician certification of terminal illness form Preview on Page 1

See details

4 out of 5

57 votes

The document is a certification form for physicians to declare a patient's terminal illness, indicating a life expectancy of six months or less. It includes sections for initial certification and re-certification, requiring signatures from the attending physician and medical director, along with verbal certification details.

Here's how it works

01. Edit your physician certification of terminal illness form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send certificate of terminal illness via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out certification terminal illness with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the certification terminal illness document in the editor.
In the 'Initial Certification Statement' section, enter the date range for certification. Fill in the patient's name and diagnosis, ensuring accuracy as this is crucial for medical records.
For 'Verbal Certification from', input the attending physician's name and have them sign in the designated area. A staff member should also provide their signature and date.
Repeat similar steps for the 'Re-Certification Statement', entering the new date range, patient details, and obtaining necessary signatures from both the physician and staff member.

Start using our platform today to easily complete your certification terminal illness form online for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the document for terminal illness?

To receive hospice care, certification of terminal illness is mandatory.

What does CTI mean in hospice?

A Terminal Illness benefit claim is a claim that can be made for your superannuation account balance and insurance benefits (if applicable) if its medically determined that that your illness or injury is terminal, and you have less than 24 months to live. The payment is generally tax-free.

What is included in terminal illness?

The easiest way to show you have a terminal illness is to ask your GP or another doctor or consultant to fill in a form - its called an SR1 or a DS1500. This form gives the DWP evidence about your illness and treatment.

What is a certificate of terminal illness?

I docHub that John Doe is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. 78 year old male with a diagnosis of stage four lung cancer.

cti form hospice

Certification of terminal illness form Sample hospice certification of terminal illness CMS hospice certification requirements Hospice recertification Checklist Medicare hospice CTI requirements Hospice CTI narrative Examples Medicare hospice recertification guidelines Hospice recertification timeline

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more