Fillable PHYSICIANS CERTIFICATION FOR MEDICAID HOSPICE BENEFIT RECERTIFICATION STATEMENT

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PHYSICIANS CERTIFICATION FOR MEDICAID HOSPICE BENEFIT RECERTIFICATION STATEMENT

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PHYSICIAN’S CERTIFICATION FOR MEDICAID HOSPICE BENEFIT
RECERTIFICATION STATEMENT FOR 60-DAY PERIOD
RECIPIENT INFORMATION
Recipient Name:
Medicaid ID Number:
or
Social Security Number:
I certify that the above beneficiary is still considered terminally ill with a life expectancy of six
(6) months or less, if the terminal illness runs its normal course. Additional 60 day periods are
covered until revocation or termination for other reasons such as ineligibility, or death.
Recertification is required for each 60 day benefit period, (after the end of the third benefit
period.) The request for extension must be received by Department for Medicaid Services (DMS)
five (5) days prior to the end of the 60 day benefit period.
Effective date of recertification:
Terminal diagnosis:
Brief narrative statement: (Review the individual’s clinical circumstances and synthesize the
medical information to provide clinical justification for a continuation to hospice services.)
ATTESTATION
By signing, I confirm that I composed this narrative based on my review of the patient’s
medical record and/or my examination of the patient.
(Hospice Medical Director Signature)
(Date signed)
SUBMIT FORM
Submit the completed form to the QIO.
MAP-377
(Rev. 09/11)
CLEAR FORM
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PHYSICIANS CERTIFICATION FOR MEDICAID HOSPICE BENEFIT RECERTIFICATION STATEMENT

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Completed 9 July 2021

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