Certification of Illness and Medical Waiver

Certification of Illness and Medical Waiver

Healthcare Provider Certification of Terminal Illness and Medical Clearance to be completed by Physician / Provider
Patient Information
My Final Wish Applicant’s Name (the “Wish Applicant”):

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Medical Provider Information
Physician Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical License Number
License Issuing State
Patient Medical Information
Wish Applicant’s Diagnosis(es):
Other Comorbidities:
Functional Status measured in Karnofsky Performance Status or ECOG:
Does the Wish Applicant have any special medical needs, such as oxygen or equipment, that require special accommodations during their Wish?
If YES, please provide a detailed list:
Does the Wish Applicant have the cognitive capacity to participate in their Wish in a meaningful way?
If No, please explain below:
Does the Wish Applicant have a prognosis of six (6) months or less OR would not be able to actively participate in the requested Wish beyond the next six (6) months?
If No or Uncertain, please explain below:
I, {physicianName}, certify that I am the treating physician of the Wish Applicant. To the best of my knowledge, my patient, the Wish Applicant, has a life expectancy of six (6) months or less OR my patient could not actively participate in the requested Wish beyond the next six (6) months. I certify that my patient is of sound mind, and capable of signing legal documents. I have discussed the Wish request with my patient and have deemed it safe and reasonable if his/her Wish is granted within the next (3) three months.
Physician Signature
Should be Empty:

Certification of Illness and Medical Waiver

Patient Information

Medical Provider Information

Patient Medical Information