Certification CTI – Medical Director

Certification #1: Statement for First 90 days period

I certify that has a life expectancy of six months or less, if the terminal illness runs its normal course.

Verbal Authorization Date: Obtained by:

Effective Date of Certification:

Primary DXSecondary DXComorbidities:Medical RecordsTeam AssessmentFace to Face EncounterADL: Functional Status: LCD Determination Status: RN Assessment Narrative: Physician Narrative:

Medical Director Attestation/Certification

I attest/confirm that I composed this narrative based on my review of patient’s medical records, team assessment and/or examination of the patient.
Medical DirectorPhysician DesigneeReferring MD (if attending)