DEPARTMENT OF PUBLIC WELFARE CERTIFICATION OF TERMINAL ILLNESS 1 RECIPIENT NUMBER 2 RECIPIENT NAME ("PATIENT") I hereby certify that the above named Patient has been diagnosed as having the following disorder: 3 WRITTEN DIAGNOSIS 4 ICD/CM DIAGNOSIS CODE and that it is my professional opinion that the Patient has a life expectancy of six (6) months or less. Initial Certification Recertification 5 SIGNATURE OF PATIENT'S ATTENDING PHYSICIAN 6 DATE 7 SIGNATURE OF MEDICAL DIRECTOR 8 DATE 9 SIGNATURE OF INTERDISCIPLINARY TEAM PHYSICIAN 10 DATE MA 372 11/14 HOSPICE American LegalNet, Inc. www.FormsWorkFlow.com