Free 48736.PDF - Indiana

MEDICAID HOSPICE PHYSICIAN CERTIFICATION
State Form 48736 (R2 / 12-02) / OMPP 0006

The information contained on this completed form is CONFIDENTIAL according to 405 IAC 1-16, 5-2-10.1, 5-2-10.2, 5-5-1, and 5-34.

A. RECIPIENT INFORMATION
Name of recipient (last, first, middle initial) Recipient's Social Security number

Primary hospice diagnosis (ICD-#):

Recipient's Medicaid number

B. PROVIDER INFORMATION
Name of hospice provider Hospice Medicaid provider number

Please check the appropriate benefit period below:

1st hospice benefit period 2n hospice benefit period 3rd hospice benefit period

______________________________________ ______________________________________ ______________________________________

Should additional hospice care be required after the first 60 days of the Third Benefit Period, please complete this page again and check the appropriate box below.
THIRD BENEFIT PERIOD (SUBSEQUENT 60 DAY PERIODS)
2nd 60 days 3rd 60 days 4th 60 days 5th 60 days 6th 60 days

Please specify the number of any subsequent benefit period _________________________ C. Having reviewed this patient's care and the course of his / her illness, I certify that this patient's medically predictable life expectancy is (6) months or less, given that the illness runs its normal course, as evidenced by the following clinical indications.

Signature of Attending Physician (Required first hospice benefit period)

Certification date (month, day, year)

Signature of Medical Director or Hospice Physician

Certification date (month, day, year)