CTI Form C

Path: Orders>Demand Documents>Certification of Terminal Illness
Path: Patient >Documents >Certification of Terminal Illness

You can generate the CTI form C for 60 days and all subsequent recertifications of the hospice period of care after the first 180 days covered by the forms A and B.

Form C shows the basic patient information (from Patient>General>Basic), hospice benefit information (from Patient>General>Admissions & Status), face-to-face encounter attestation (entered using the H - HO Face-to-Face Encounter clinical note), and a brief narrative statement (entered using the B - CTI Brief Narrative Statement clinical note).

To preview CTI form C, define the MD CTI in the Certification of Terminal Illness window.

Hospice Face-to-Face Encounter

The purpose of the face-to-face encounter note is to show when the face-to-face encounter was provided.

In addition to MD CTI, nurse practitioners or other hospice physicians can provide the face-to-face encounters. In this case, the Face-to-Face Encounter section has a frame around it, the attestation text is changed appropriately, and the signature fields captions are changed to indicate who provided the encounter (see CTI Form C for NP Providing Face-to-Face Encounter and CTI Form C for MD Providing Face-to-Face Encounter).

The actual notes of the face-to-face encounter do not appear on the form C, only the attestation that the encounter was provided with date, signature, and name of physician is shown.

Brief Narrative Statement

The brief narrative statement can also include information on whether the physician can recertify that the patient's life expectancy is six months or less. If this information is entered in the clinical note, then the corresponding check box on the form (above the brief narrative statement) is selected. If not, the recertification can be done further on the printed form.

If B and H clinical notes are provided, the date (provided date) and physician name are taken from these notes and printed on the form. If clinical notes are not added, then there is a space for adding the date and signature manually on the form and the physician name is taken from the MD CTI field in the Certification of Terminal Illness window.

If the B and H clinical notes were signed in the Electronic Signature dialog of the Clinical Notes Window or entered through Physician Portal, Electronically Signed by will be displayed on the form, where is the name of physician who signed the form.