Certification CTI – PCP – Savior Hospice Care

Certification CTI
(PCP)

We require a physician’s authorization and a brief explanation of the patient’s terminal illness in order to determine a patient’s eligibility for Hospice benefits.

Statement for First 90 days period

Verbal Authorization Date: Effective Date of Certification: Terminal Diagnosis:

If the terminal illness proceeds normally, this patient, in my clinical judgment, has a life expectancy of six months or less. My signature authorizes admission to Hospice. If I choose to follow the Patient, I have been encouraged to participate in the IDG Meetings and Care Plan.

Name: Referring MDPCPOther MDSignature: Referring MDPCPOther MDPatient Follow-Up:
If there is a need to alter the current care plan, I do want to be contacted directly. In the event of my absence, the hospice physician may be appointed. The Death Certificate needs my signature. For the purpose of managing symptoms and pain, the hospice physician can follow.Do not wish to sign the death certificate or follow the patient.

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Certification CTI – PCP