Answer:
A certification of terminal illness from a physician must include the following:
(1) A statement that the individual’s illness or physical condition can be reasonably expected to result in death in 84 months or less after the date of certification;
(2) A narrative description of the evidence that was used to support the statement of illness or physical condition;
(3) The name and contact information of the physician making the statement.
(4) The date the physician examined the individual or reviewed the evidence provided by the individual, and the date that the certification is signed by the physician; and
(5) The signature of the physician making the statement, and an attestation from the physician that, by signing the form, the physician confirms that the physician composed the narrative description based on the physician’s examination of the individual or the physician’s review of the evidence provided by the individual.
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